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June 2000

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COMMENTARY

Submerging Technology
Hyperbaric Medicine

By Samuel E. Landrum, MD, FACS

For more than a century hyperbaric chambers have been
in use for the treatment of divers suffering bends. (More
than 100 were affected during construction of the Eads
Bridge across the Mississippi River in St. Louis).

The benefit in this instance relates to compressing nL
trogen bubbles. This same effect explains its use for arte-
rial gas embolism. In the last half of the 20th century, it
was found that oxygen, when administered at two or more
atmospheric pressures, would dissolve in plasma in suffi-
cient amounts to maintain vital functions thereby reviv-
ing the victim of carbon monoxide poisoning. Thus the
hemoglobin bound by carbon monoxide was not required
for oxygen transport.

Gas gangrene due to Clostridia is another highly le-
thal disease that is helped by hyperbaric oxygen treatment
(HBOT). The alpha toxin of Clostridia is neutralized, and
the progression of the systemic toxicity is halted. Aggres-
sive debridement must be done, as well as antibiotic and
supportive treatments.

During the more recent three decades it has been found
that HBOT is of substantial adjunctive benefit in achiev-
ing healing in chronic wounds from arterial obstruction,
mostly in the lower limbs. These wounds are encountered
often by diabetic patients, especially those with neuropa-
thy and impaired vascularity of their feet. Meticulous
wound care, control of metabolic problems and infection,
relief of pressure and shearing forces, and many other fac-
tors remain necessary components of the patient’s care if
success is to be achieved and sustained. For diabetics the
rate of amputation or level of amputation is improved sev-
enfold when patients receive HBOT compared to those
treated with local wound care alone.

Chronic refractory osteomyelitis is another indication
for HBOT as an adjunct in the treatment. Improved func-
tion of leukocytes, neovascularity of the wound area and
enhanced potency of aminoglycosides are some effects.

Some ill effects of radiation on bone and soft tissues
are reduced by HBOT. Skin grafts or flaps that are failing
are helped by HBOT, obviating the need for further graft-
ing. Other uses are for patients with crush injuries and some
burns. Other problems treated with HBOT, such as recluse
spider bites and neurological diseases, are investigational
and not widely recognized as appropriate indications.

During the first year of operation of a hyperbaric pro-
gram at a regional medical center, more than 160 patients
were evaluated for HBOT with 87 treated. Another 26 who
were considered candidates could not undergo enough
treatments to evaluate its effect; most of these patients had

claustrophobia or problems equalizing middle ear pressure
well enough to permit pressurization within the chamber.

The results of those treated are summarized in the fol-
lowing table. Those benefited include patients whose am-
putation level was more distal than otherwise expected,
patients who had grafts successfully cover a serious wound
and patients who have not had enough treatments to
achieve healing yet.

These patients were treated by accepted protocols for
an average of 25 HBOTs, with a few healing quickly or

Diagnosis

Healed

Benefited

No Benefit

Arterial Obstruction,
Lower Limb with
Chronic Wound

Osteomyelitis

Radionecrosis

Failed Graft

Crush Injury

Electrical Burn

Fournier’s Gangrene

giving evidence of no benefit or receiving their defini-
tive operation quickly, and several requiring treatments
for eight to 20 weeks for optimum outcomes. This group
includes people with multiple co-morbidities as evidenced
by the fact that nine of these patients have died subse-
quently. Sixteen percent had no benefit, 42% healed and
42% were significantly helped by HBOT in the adjunc-
tive treatment of wounds with healing problems with or-
dinary care.

This old treatment has not been widely applied. Its indi-
cations and appropriate uses are being recognized increasingly.
With the population living longer — and especially with the
high incidence of diabetes mellitus — the need for such
therapy can be expected to increase to provide better care of
patients with wounds that have defied our best efforts. ■

Space is not available to discuss contra-indications and many
details that are taught in a 60-hour course. These are just some
highlights .

Dr. Samuel E. Landrum is a retired general surgeon from Fort
Smith. Dr. Landrum is a member of the editorial board for The Jour-
nal of the Arkansas Medical Society.

Number 1

June 2000 • 7

COMMUNICATIONS COORDINATOR

Judy Hicks

EXECUTIVE VICE PRESIDENT

Kenneth LaMastus, CAE

ASSISTANT EXECUTIVE VICE PRESIDENT

David Wroten

EDITORIAL BOARD

Jerry Byrum, MD
Joseph M. Beck, II, MD
Lee Abel, MD
Samuel Landrum, MD
Jerry Kendall, MD
William Ackerman, MD

Pediatrics
Oncology
Internal Medicine
Surgery
Family Practice
Anesthesiology

EDITOR EMERITUS

Alfred Kahn Jr., MD

ARKANSAS MEDICAL SOCIETY
2000-2001 OFFICERS

Gerald A. Stolz, Jr., MD, Russellville
President

Joe Stallings, MD, Jonesboro
President-elect

Paul A. Wallick, MD, Monticello
Vice President

Lloyd G. Langston, MD, Pine Bluff
Immediate Past President

CarltonL. Chambers, III, MD, Harrison/Litde Rock
Secretary

Dwight M. Williams, MD, Paragould
Treasurer

Anna Redman, MD, Pine Bluff
Speaker, House of Delegates

Kevin Beavers, MD, Russellville
Vice Speaker, House of Delegates

Joseph M. Beck, II, MD, Little Rock
Chairman of the Council

Established 1890. Owned and edited by the Ar-
kansas Medical Society and published under the di-
rection of the Council.

Advertising Information: Contact Stephanie
Hopkins, P.O. Box 3686, Little Rock, AR 72203;
(501) 372-2816.

Postmaster: Send address changes to: The Journal
of the Arkansas Medical Society, P. O. Box 55088,
Little Rock, Arkansas 72215-5088.

Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.

The Journal of the Arkansas Medical Society
(ISSN 0004- 1 858) is published monthly by the Arkan-
sas Medical Society, #10 Corporate Hill Drive, Suite
300, Little Rock, Arkansas 72 205 . Printed by The Ovid
Bell Press, Inc., Fulton, Missouri 65251. Periodicals
postage is paid at Little Rock, Arkansas, and at addi-
tional mailing offices.

Articles and advertisements published in The Jour-
nal are for the interest of its readers and do not
represent the official position or endorsement of T he
Journal or the Arkansas Medical Society. The Journal
reserves the right to make the final decision on all
content and advertisements.

8 • The Journal

Volume 97

WHAT WE’VE DONE FOR YOU LATELY

Wish You Had
Been There

By David Wroten

The 1 24th Annual Session of the Arkansas Medical Society is now history.
We’ll feature highlights from the meeting in next month’s issue of The Journal.
However, I want to use this month’s space to tell you what a success the meeting
was and to set the stage for getting YOU there next year.

On May 5-6, more than 200 physicians, residents and students turned out for
the AMS annual meeting held in Little Rock at the Embassy Suites. Months of
planning and revisions paid off in what some long-time attendees agreed was one of
the best annual meetings in AMS history.

What made it so great? The revised schedule certainly helped. All of the educa-
tional programs were on one day, followed by only one day of business meetings. In
the past, the educational programs and business meetings were spread over three
days. Those attending mostly business sessions had to plan on two or three days
away from home and practice for what amounted to less than a full day of actual
meetings. The same was true for those interested only in the continuing medical
education programs. As a result of the change, attendance at both CME and busi-
ness meetings was up significantly.

The topics for the CME activities were another big plus. The topics were current
and applicable to a broad range of medical specialties. You he the judge: Biological
Terrorism & Medicine; Medical Discoveries in Space; Gene Therapy; Overuse of
Antibiotics; and How Can the Internet Help Deliver Efficient, Quality Health Care?

Our efforts to encourage young physicians to attend and become involved were
bolstered by the Young Physician Seminar. Nearly 60 young physicians and resi-
dents attended a special seminar on joining a group practice or partnership. For a
young physician, joining that first practice is both exciting and frightening. Having
sat through most of the seminar myself, I can assure you that the physicians who
attended are now in a much better position to make wise, informed decisions re-
garding their future.

No educational meeting is complete without a trade show. It’s not easy to get
physicians to visit an exhibit center to spend quality time with the various company
representatives, especially when there are 80-90 different booths. So we reduced the
number of booths to 45. The result: Physicians spent more time with each exhibitor,
and more physicians visited the exhibit hall. The commercial sponsors and exhibi-
tors underwrite the majority of the annual session expenses. We appreciate their
support and can’t say thank you enough.

The business meetings on Saturday were capped with the election of officers
and the installation of E)r. Gerald Stolz, a Russellville pathologist, as the new AMS
president. Dr. Joe Stallings, a Jonesboro family practitioner, was chosen as presi-
dent-elect and will assume the office of president at next year’s annual session.

U.S. Representative Marion Berry from the 1 st Congressional District received
the Shuffield Award. The AMS recognized him for his efforts in sponsoring and
passing the Patient’s Bill of Rights in the U.S. House of Representatives. The Shuffield
Award is the highest honor that the AMS bestows on a non-physician.

Bottom line: The 1 24th Annual Session was well attended and proved to be a
huge success for all involved. The new format makes it easier for physicians to com-
mit the time to attend. Our thanks to those physicians, residents and medical stu-
dents who attended, and our appreciation to the sponsors and exhibitors for their
contributions and support. We hope to see more of you there next year! ■

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Physicians Give
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SHIRLEY CARSON, 60, QUITE
possibly might have died last year if
she hadn’t undergone double heart
bypass surgery.

Because of an organization that is
housed in the Arkansas Medical Society’s office
and founded by AMS, Carson was able to get
the $22,000 procedure for free. And that doesn’t
include the countless office visits with her
family physician, Dr. George A. McCrary
of Cabot, and her cardiovascular physi-
cian, Dr. Mark St. Pierre of North Little
Rock. All those visits are free, too.

Before signing up to receive care
through the Arkansas Health Care Access
Foundation Inc., Carson was postpon-
ing taking care of her and her
husband’s health problems.

“I had quit going to the doctor,
because at $80 a visit, we just
could not afford it on our limited
income,” she said.

With extensive health
problems, ranging from a bad
heart condition, severe arthritis,
diabetes and back pains, Carson
cannot keep a frill-time job. But
she has been turned down for
disability benefits and is still too
young to qualify for Medicare.

The Arkansas Health Care
Access Foundation was created
to help these exact types of
patients. The state’s “working poor”
and uninsured have always been the
) big losers when it comes to health care
access, said Dr. Harold Hedges, a Little

Lovie Casey, a patient in the Arkansas
Health Care Access Foundation program,
gets a check-up.

June 2000 • 1 1

By Natalie Gardner

The turn of the century
might bug an
ordinary hospital.

Fortunately, we have some prior
experience with such bugs. In fact,
a turn of the century bug was how
St. Bernards came to be in the first place.

In 1900, St. Bernards Hospital was founded
in a six-room frame house to respond to the
region’s malaria epidemic — spread by none
other than the common female mosquito.

In the 100 years since then, St. Bernards has
continued to respond to the needs of our
community. No longer simply a respite for
the ailing, St. Bernards has grown into a
regional referral center providing total
healthcare services and education to
communities all over Northeast Arkansas
and Southeast Missouri.

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Rock family practitioner and former
chairman of the foundation’s board of
directors.

“We noticed a number of patients
who were falling through the cracks
as far as medical treatment was con-
cerned,” Hedges said. “They were
folks who worked and their employer
couldn’t supply insurance, and they
couldn’t afford to pay it themselves.
It was a huge population of people that
didn’t qualify for any state or federal
programs.”

In 1989, the Arkansas Medical
Society created the foundation and
modeled it after a similar program in
Kentucky. Asa Crow, a retired physi-
cian in Paragould, was instrumental in
forming the Arkansas Health Care
Access Foundation.

Arkansas was the second of four
states in the United States to create a
comprehensive, volunteer health care
program for the “working poor,” said
Program Director Pat Keller.

An estimated $6 million in medi-
cal care and treatment has been pro-
vided by the program’s 1,900 volun-
teers at an average cost of $20 per en-
rollee. AMS supports the programs
through in-kind donations, such as
support staff, office space and utilties.

Arkansas residents can apply for
the program through their local county
Department of Human Services of-
fice. To be eligible for the program,
applicants must be a U.S. citizen, be a
resident of Arkansas, meet the cur-
rent Federal Poverty Guidelines ac-
cording to family size, not have any
form of medical insurance, including
Medicaid or Medicare, or Veteran’s
Administration medical benefits, and
not have more than $2,000 in liquid
resources.

Income level cutoffs for a family of
two is $937.50 per month and $1,420.83
per month for a family of four.

Once admitted to the program, pa-
tients receive a toll-free number to call
when they need any type of health care

12 • The Journal

Volume 97

services. Doctors who volunteer their
time for the program are only required
to see a patient once, but many, like
Dr. Hedges and Dr. Bart Throneberry
of Conway, continue to do follow-up
sessions with patients.

“With all the time spent on man-
aged-care rules and regulations, I can
do this because I want to,” Dr.
Throneberry said. “It makes me feel
really good to do something that helps
others. This program goes to the heart
of why people wanted to be a doctor
— to help those who need to be
helped. It’s easy to lose sight of that.”

Recruiting Volunteers

Currently, more than 1 ,900 volun-
teer health professionals, including
1,100 physicians, volunteer for the
program. Along with the physicians,
many of the state’s pharmacists, po-
diatrists, dentists, home-health agen-
cies and hospitals volunteer their time
and resources to provide free care to
patients.

“We don’t have a formal agree-
ment with any of the doctors,” Keller
said. “If a doctor decides in six months
that he needs to limit the number of
referrals he is getting, then all he has
to do is call. We’re very accessible to
our volunteer physicians.”

Many of the family physicians
who volunteer see two-three patients
a month. Some of the specialists
don’t see a patient for months, but
then will see two patients the next
month. Currently, the foundation is
in need of more physicians in east-
ern Arkansas.

Part of the nonprofit’s services in-
clude arranging for free medications
for patients. Getting doctors’ visits
paid in full helps patients a great deal,
but some patients have just as much
expense when they fill their prescrip-
tions, Keller said.

“Two-thirds of the pharmacies in
the state volunteer their services, giv-
ing patients prescriptions at cost,” she

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said. “That helps, but so often that is
not enough. That’s when we went di-
rectly to the drug companies to see
what they could do.”

If a physician prescribes medica-
tions from either Pfizer Pharmaceuti-
cals, Johnson & Johnson or SmithKline
Beecham Pharmaceuticals, the cost to
patients is none.

“These companies have been a life-
saver for us,” Keller said. “We really
encourage the doctors to use medica-
tions from these companies. We tell the
patients to take the list of all these
medications with them to the doctor to
help remind the physicians what will be
paid for.”

Keller and her 20-member board
of directors also hope some of the bil-
lions of dollars in tobacco money com-
ing to the state will be directed to the
program. Currently, the foundation’s
main source of funding is a contract with
the Department of Human Services.

“The board of directors is concerned
we’re going to be left out when the to-
bacco money is distributed,” Keller said.
“I feel that we are in a good position —
we’ve got a screening process in place
for patients, we have good relationships
with our providers and we have a large
database of patients. We just want to
make sure that part of that money is set
aside to take care of this population,
maybe through partial reimbursement
to doctors or partial reimbursement for
follow-up care or for illnesses due to
smoking.”

Lending a Helping Hand

The real joy for Keller, her staff and
the volunteers associated with the pro-
gram is the difference they are making
in patients’ lives.

“I’m doing this program because I
choose to,” Dr. Throneberry said. “Doc-
tors, recently, have been so angry, frus-
trated and busy with rules and regula-
tions, we sometimes forget why we do
what we do. Treating these patients helps
me bring things back into perspective.”

14 • The Journal

Volume 97

And the patients truly are grateful.

“For me, it’s the initial doctor visit
that is such a big help, and my really
expensive prescriptions are free,” said
Brian Brengle, 33, a Hot Springs min-
ister in the program.

Brengle, who makes about $500 a

asked to be anonymous said even
though she couldn’t afford her care, she
was treated with the utmost respect by
all of her care givers.

“Sometimes when people cannot
afford to pay for things, they don’t get
good treatment,” she said. “But that has

capable of paying any medical ex-
penses. Until she gets better and can
go back to work, the foundation has
been a “blessing,” she said.

“There’s no way I could have af-
forded to get a mammogram or a
colonoscopy without them,” she said.

“The doctors in this program are a better quality
than what I got in my HMO.” — Brian Brengle, 33.

month, has struggled with paying steep
medical bills. He qualified for the pro-
gram in 1994 and has gotten free treat-
ment for severe arthritis, high blood
pressure and a spastic colon.

“I used to have an HMO [health
maintenance organization] when I could
afford it,” he said. “The doctors in this
program are a better quality than what I
got in my HMO.”

A former nurse in her 50s who

not been my experience with this pro-
gram. There was no partiality shown to
[paying patients]. I was treated just like
everyone else.”

The Arkansas Health Care Access
Foundation often helps people like
this nurse. She was injured in a car
accident in 1996 and stopped work-
ing because of severe hip and back
injuries. Prior to the accident, she was
making a comfortable salary and was

“It’s been a blessing in disguise for me.

“If I was in a position right now
to donate my [nursing] services, I
would. Any [health care professional]
who is able to participate in this pro-
gram could get so much satisfaction
from helping the people who need it
the most.” ■

Christy L. Smith contributed to
this report.

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Number 1

June 2000 • 1 5

By Christy L. Smith

Meet Our Members

James Harrell Jr., MD

16 • The Journal

Dr. James Harrell Jr. has performed more than 100 heart
transplants at Arkansas Children’s Hospital since the
institution’s pediatric heart transplant program was estab-
lished in 1991.

But the 47-year-old cardiovascular surgeon and surgical
director of the ACH Heart Center appears to still be amazed
by the miracle of life.

“I’ve done a fair amount of adult surgeries, hut pediatrics
is a suhfield of cardiovascular surgery that I particularly en-
joy. It is tremendously satisfying to take a baby, fix his heart
and know that you have changed his life expectancy, given
him another 50 or 60 years of life,” Dr. Harrell said.

The surgeon performs eight- 10 cardiovascular pro-
cedures — closing holes in a patient’s heart and recon-
structing valves, arteries and heart walls — - per week;
and he conducts an average of 12 pediatric heart
transplants per year.

Most of Dr. Harrell’s transplant patients hail from
Arkansas, but ACH also takes referrals from Missis-
sippi, Louisiana, east Texas, east Oklahoma and Ten-
nessee. Two former patients even traveled from as
far as Kansas and Connecticut to receive a heart trans-
plant on Dr. Harrell’s surgical table.

“For a children’s hospital, we have a lot of volume,”
he said. “We’re really proud of the program
. . . Arkansas is often seen as a poor
Southern state, but we are
achieving astounding things
in the medical field here.”

Setting an
Example

There are
only 141 heart
transplant /
programs in
the coun-
try,
ac-

/ , f

cording to the United Network for Organ Sharing, the agency
that matches organ donors with waiting recipients, and Dr.
Harrell oversees the only pediatric heart transplant program
in Arkansas.

A U.S. Department of Health and Human Services re-
port issued this year ranked the heart transplant program at
Arkansas Children’s Hospital ninth in the nation for one-year
survival of patients after placement on
a waiting list. ACH heat the na-
tional average of 75.8% by
8.8 percentage points.
Only two other
children’s hospitals
made the list — All
Children’s Hospital in
Florida (fourth) and
Children’s Memorial
Hospital in Chicago
(eighth).

ACH also ranked 1 0th
for transplants completed
within one year of patient
placement on the waiting list.
The national average was
53.7%; the ACH aver-
age was 72.4%.

Only three

v ■ ■!/

other children’s hospitals made that list
— All Children’s Hospital in Florida
(first), Children’s Hospital in Denver
(third) and Children’s Hospital in Bos-
ton (sixth).

The World of Medicine

Dr. Harrell’s talents were nearly lost
to the medical profession when, as a
Harvard University undergraduate, he
became interested in global economics.

Tire son of a physician and Army re-
servist, Dr. Harrell spent much of his
childhood growing up in south Arkan-
sas, Texas and Washington, D.C. He stud-
ied economics at Harvard until he was
accepted into the DeBakey Surgical Sum-
mer Scholarship Program at Houston’s
Baylor College of Medicine.

For three months in 1974, he fol-
lowed the work of Dr. Michael E.
DeBakey, a world-renowned medical pio-
neer who served as a consultant on the
1996 bypass surgery of former Russian
President Boris Yeltsin.

“I saw everything that summer —
heart surgeries, gun shot wounds. It was
all so interesting and exciting. I immedi-

ately changed my career path,” he said.

After graduating from Harvard with
a general studies degree — he did not
complete his senior thesis in economics
— Dr. Harrell entered Baylor College of
Medicine, where his father is now chief
of radiology.

He completed general surgery resi-
dencies at Baltimore’s Johns Hopkins
University Hospital and Houston’s Uni-
versity of Texas Health Science Cen-
ter, a two-year thoracic surgery resi-
dency at Baylor, a cardiovascular re-
search fellowship at Baylor and a pedi-
atric cardiovascular surgery fellowship
in London, England.

From 1980-89 he also found time
to serve in the U.S. Army Reserve
Medical Corps, in which he taught a
combat casualty care course and
achieved the rank of major.

Dr. Harrell spent two years practic-
ing in California before moving to Little
Rock to become attending staff surgeon
and acting chief of staff at ACH in
1989. He also has surgical and admin-
istrative responsibilities at the VA
Medical Center and University Hospi-

tal, both in Little Rock; and he was di-
rector of the thoracic surgery residency
program at the University of Arkansas for
Medical Sciences from 1990-98.

Dr. Harrell is a member of the
Governor’s Task Lorce on Organ Donation,
a group trying to increase the rate of organ
procurement in this state, and 1 1 other pro-
fessional organizations. He has been a
member of the Arkansas Medical Society
since 1989 and has participated in the
society’s “Doctor for a Day” program.

Dr. Harrell said the Arkansas Medical
Society has been an “invaluable” resource
for information about the legislation affect-
ing Arkansas patients and physicians.

“I am particularly grateful for the
Medical Society’s involvement in state
legislative affairs. It has certainly taken
an active role in advocating for the pro-
tection of patients’ rights and, likewise,
looking out for the interests of Arkansas
physicians,” he said.

He is married to Marty Harrell, a CV
nurse at Arkansas Children’s Hospital, and
has three children from a previous mar-
riage — one son, Wells, 15; and two daugh-
ters, Elizabeth, 13, and Lauren, 12. ■

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LOSS PREVENTION

Experts for
the plaintiff
contended
that the
omission of
the

preoperative
prophylactic
antibiotics
was a

negligent act.
They also
insisted there
was too much
telephone
treatment and
not enough
direct
observation
by the
physicians
early in the
case.

Negligence or Not

J. Kelley Avery, MD

A 5 1 -year-old housewife who was the prin-
cipal caregiver for a paraplegic husband saw an
orthopedic surgeon for pain in both feet, worse
on the right. She thought she had some painful
calluses on her feet that caused pain when she
stood.

The pain became worse the longer she was
on her feet. Caring for her husband required
that she be up and on her feet most of every
day. Examination revealed pain on lateral com-
pression of the metatarsal heads bilaterally. She
also had a positive “pinch test” over the web
spaces between the second, third and fourth
metatarsals. She was thought to have neuro-
mas between the second and third and the third
and fourth metatarsals. Both interspaces were
injected with steroids on that visit. She did not
improve.

Two weeks later the patient was admitted
to an outpatient
surgical center for
removal of the
neuroma. No pro-
phylactic antibiot-
ics were given
preoperatively.

The operation was
carried out in the
usual manner, us-
ing general anes-
thesia and a pneu-
matic tourniquet.

Incisions were made in both interspaces, and
by blunt and sharp dissection, neuromas were
removed from both interspaces. Gelfoam was
placed in both incisions, and when the tourni-
quet was released there was good blood flow. A
pressure dressing was applied, and after fully re-
covering from the anesthesia, the patient was
sent home to return to the surgeon’s office in
one week. The pathology report confirmed the
diagnosis.

After midnight the following day, the pa-
tient had to go the emergency department be-
cause of severe pain in her foot not relieved by
oral narcotics. There was no report of the emer-
gency visit in the record of the surgeon. The
patient phoned the office and reported the visit

stating that two toes were purple and cold.
The dressing was rewrapped, and she was in-
structed to call. Later the same day the office
called, and the patient stated that she was,
“much better this morning.”

The office records do not document the
visit that occurred one week after surgery.
Three days after this visit was to take place,
the office records show that Vicodin No. 100
were called to the pharmacy for the patient.
The next day she called to report swelling
every time she got up on her feet.

The swelling subsided on elevation of the
foot. She wanted to know if this was nor-
mal. She stated that she had an appointment
in three days for the stitches to be removed
and the record quotes the patient, “Please
call.” She was reassured that the swelling was
normal and that she should keep the foot el-
evated as long as
this swelling con-
tinued.

On the day
appointed, two
weeks after sur-
gery, the sutures
were removed.
She was seen by
an associate of
her surgeon’s
who recorded
“rather massive”
blood clot under the skin at the operative
site. She was given antibiotics and told to
use salt water soaks and to return in a week.
Four days later she was seen in the office.
Although there is no documentation of this
visit other than that she was in the office. I
presume that the operative site “hematoma”
was drained. Two days later, there was a re-
port of “heavy growth of staph aureus” from
the drainage, and the patient was admitted
to the hospital. Having been seen in the of-
fice and the emergency department by an as-
sociate of her operating surgeon, she stated
her preference to continue to see the associ-
ate, but the operating surgeon assumed her
care on that admission. Two ulcerations were

Number 1

June 2000 • 19

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present on the dorsum of the foot
draining purulent material.

She was in the hospital for two
weeks receiving intravenous Kefzol
and Gentamicin, and physiotherapy
(whirlpool). While in the hospital, de-
bridement of the operative sites was
done, with the removal of devitalized
tissue. At the time of discharge from
the hospital there did not appear to be
any active infection, and the wounds
were said to be healing and clean.

A home health nurse was in her
home attending her husband and re-
ported that the drainage coming from
the wound “was greenish in color and
had a foul odor to it.” She was seen
the next day in the office by the asso-
ciate, who changed antibiotics and pre-
scribed daily whirlpool treatments. It

The physician elected to
resume antibiotics. A week
later, when the patient
reported more discolored
drainage and "red streaks”
from the toes to the ankle
area, she was readmitted to
the hospital.

was then two months since the opera-
tion, and the wound was draining and
showing lots of “debris.” The physi-
cian elected to resume antibiotics. A
week later, when the patient reported
more discolored drainage and “red
streaks” from the toes to the ankle
area, she was readmitted to the hos-
pital.

Antibiotics were changed again.
Shortly after the first dose of the new
antibiotic the patient had a seizure
from which she recovered spontane-
ously. She had an EEG done, which
was “abnormal.” The consultant said
she had a “predisposition to seizures.”
The conclusion was that the seizure
was due to a reaction to the antibi-

20 • The Journal

Volume 97

A lawsuit was filed against both surgeons who treated
this patient charging negligence in not giving
preoperative antibiotics; wrapping the dressing too
tightly; failure to continue the antibiotics following
discharge from the hospital after the first admission;
and failure to consult an infectious disease specialist.

otic. She was seen
by a plastic surgeon
about the possibib
ity of covering the
wound to enhance
healing. This was
not done. MRI
failed to show any
evidence of osteo'
myelitis, and after a
month in the hospb
tal, the patient was sent home to con-
tinue intravenous antibiotics via a
Hickman catheter and under the super-
vision of the home health nurse.

Finally, six months after the initial
operation, the wound appeared healed,
but there was still severe pain in the
foot. The patient would require another
operation to remove “stump neuroma”
at both original sites, and she would sub-
sequently be hospitalized seven more
times because of problems with her foot.

A lawsuit was filed against both sur-
geons who treated this patient charg-
ing negligence in not giving preopera-

tive antibiotics; wrapping the dressing
too tightly; failure to continue the an-
tibiotics following discharge from the
hospital after the first admission; and
failure to consult an infectious disease
specialist. After six years of litigation, a
settlement was reached.

Loss Prevention Comments

Was this a case of negligent physi-
cian acts, or was it a case where the
outcome was certainly not good, but was
in the area of hazards that occur despite
treatment that can be considered stan-
dard and acceptable? Experts for the

plaintiff contended that
the omission of the pre-
operative prophylactic
antibiotics was a negli-
gent act. They also in-
sisted there was too
much telephone treat-
ment and not enough
direct observation by
the physicians early in
the case. Certainly af-
ter the beginning of the infections, all
physicians would have wished that the
patient had received the antibiotics. The
defendant physicians’ experts, equally
qualified in the field of orthopedic sur-
gery, stated that while many surgeons
routinely gave the preoperative prophy-
lactic antibiotics, it was not considered
“standard” at the time this surgery was
done. Many similar procedures had
been done without the prophylactic
drugs, where no serious infection had
occurred, but that is not this case.

There were factors that would have
weighted the case heavily in favor of

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Number 1

June 2000 . 21

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MEDICAL CENTER

the plaintiff had it been taken to trial.
The plaintiff was an attractive middle-
aged wife and mother. She was very in-
telligent and made a favorable impres-
sion. She had a paraplegic husband for
whom she was the principal care giver.
She had this responsibility for several
years before the surgery, and indeed it
was because of her need to care for her
husband that the surgery was necessary.
She was considered a superior witness.
The paraplegic husband was scheduled
to testify in person at the trial. He would
say that he had been emotionally dam-
aged by the absence of his wife’s care
during the long months when she was
not able to care for him. He also was
thought to be an exceptionally good
witness. A strong sympathy factor was
expected and feared.

On the other hand, the surgeon was
tentative, nervous and very much trau-
matized by a previous trial in which the
plaintiff attorney vigorously cross exam-
ined him. He was not considered to be a
good witness. He could not be relied upon
to represent himself well. His office
records were not good, and the records of
this patient’s visits to the ED were not a
part of them. The surgeon had not acted
as if it was important to see the report of
the ED physician who had actually seen
his patient and observed the wound. His
patient had gone so far as to request, in
the middle of things, that his associate as-
sume charge of her care.

The actual expenses borne by the
plaintiffs were in the six-figure range.
The settlement, in the range of two
times the actual expenses, was con-
sidered to be a victory. It may not be
right, but that is the world in which
we live.B

The case of the month is taken from
actual Tennessee closed claims. An at -
tempt is made to fictionalize the material
in order to make it less easy to identify.
Dr. A very is a member of the Loss Pre-
vention Committee , State Volunteer
Mutual Insurance Co., Brentwood,
Tenn. This article appeared in the March
2000 issue of Tennessee Medicine. It is
reprinted with permission.

22 • The Journal

Volume 97

Arkansas Department of Health HIV/AIDS Surveillance

HIV in Arkansas

Demographics

83-92

1993

1994

March 31,

1995 1996

2000

1997 1998 1999 2000

Total

Male

1622

338

342

321

262

261

286

268

3782

Female

289

904

Under 5

5-12

13-19

177

20-24

246

559

25-29

448

106

935

30-34

451

1048

35-39

310

838

40-44

167

502

45-49

262

50-54

134

55-59

60-64

65+

White

1234

264

243

252

186

179

186

190

2792

Black

661

158

177

150

142

160

149

139

1775

Hispanic

Other/Unknown

Male/Male Sex

1049

230

212

176

153

131

161

133

2268

Injection Drug

310

680

User(IDU)

M/M Sex + IDU

184

339

Heterosexual/

236

779

Known Risk

Transfusion

Perinatal

Hemophiliac

Undetermined

111

464

Total

1911

427

431

410

339

353

356

353

106

4686

100

HIV Cases by County

County 1983- Jul 98 County 1983- Jul 98
03-31-00 Jun 99 03-31-00 Jun 99

Arkansas

Lee

Ashley

Lincoln

Baxter

Little River

Benton

122

Logan

Boone

Lonoke

Bradley

Madison

Calhoun

Marion

Carroll

Miller

119

Chicot

Mississippi

Clark

Monroe

Clay

Montgomery

Cleburne

Nevada

Cleveland

Newton

Columbia

Ouachita

Conway

Perry

Craighead

Phillips

Crawford

Pike

Crittenden

210

Poinsett

Cross

Polk

Dallas

Pope

Desha

Prairie

Drew

Pulaski

1532

119

Faulkner

Randolph

Franklin

St. Francis

Fulton

Saline

Garland

183

Scott

Grant

Searcy

Greene

Sebastian

255

Hempstead

Sevier

Hot Spring

Sharp

Howard

Stone

Independence 32

Union

150

Izard

Van Buren

Jackson

Washington

343

Jefferson

193

White

Johnson

Woodruff

Lafayette

Yell

Lawrence

Prisons

152

* Case numbers 1-3 are not indicated

AIDS in Arkansas

March 31, 2000

Demographics

83-92

1993

1994

1995

1996

1997

1999

1999 2000

Total

Male

807

325

253

235

213

179

174

159

2405

Female

427

Under 5

5-12

-1

13-19

20-24

172

25-29

206

509

30-34

217

688

35-39

178

576

40-44

376

45-49

206

50-54

55-59

60-64

65+

White

658

264

189

173

145

130

116

108

1825

Black

237

120

103

116

947

Hispanic

Other/Unknown

Male/Male Sex

546

228

163

139

129

100

1531

Injection Drug

114

416

User(IDU)
M/M Sex + IDU

115

254

Heterosexual/

377

Known Risk
Transfusion

Perinatal

Hemophiliac

Undetermined

130

Total

905

388

295

271

267

225

214

189

2832

100

For More Information: HIV/AIDS Statistics: Mischelle Priebe, (501) 661-2323 ;

HIV Services: Renee Patrick (501) 661-2292; STD Statistics: Hupa Sharma, (501) 661-2139

AIDS Cases by County

1983- Apr 99- Case Rate
County 03-31-00 Mar 00 per 100,00

Arkansas

Ashley

Baxter

Benton

Boone

Bradley

Calhoun

Carroll

Chicot

Clark

Clay

Cleburne

Cleveland

Columbia

Conway+

Craighead

Crawford

Crittenden+

114

Cross

Dallas

Desha

Drew

Faulkner

Franklin

Fulton

Garland+

123

Grant

Greene

Hempstead

Hot Spring

Howard

Independence 20

Izard

Jackson

Jefferson

115

Johnson

Lafayette

Lawrence

* Case numbers 1-3 are not indicated

Lee+

0.0

Lincoln

Little River+

3.1

Logan

6.3

Lonoke

0.0

Madison

Marion

Miller+

13.2

Mississippi

Monroe+

5.7

Montgomery

Nevada

0.0

Newton

Ouachita

15.0

Perry

2.6

Phillips

2.0

Pike

20.1

Poinsett

Polk

10.9

Pope

13.1

Prairie

11 3

Pulaski+

930

3.9

Randolph

6 1

St. Francis

Saline

22.8

Scott

0.0

Searcy

0 0

Sebastian+

163

137

Sevier

7.0

Sharp

7.2

Stone

6.1

Union+

Van Buren

0.0

Washington

213

134

White

Woodruff

Yell

5.7

Prisons

Denotes top ten case rates 04/99-03/00

* 24.0

0 0.0

15.1

0 0.0

* 7.6

* 13.9

10 25.2

* 4.0

* 29.0

0 0.0

* 7.1

0 0.0

* 5.1

* 2.0

0 0.0

57 16.2

0 0.0

7.0

0 0.0

17 16.0

0 0.0

7 15.3

* 6.4

20 14.6

* 4.7

0 0.0

* 10.4

4 n/a

Number 1

June 2000 • 23

CARDIOLOGY

Iron Overload and the Heart

Nelly Kazzaz, MD — Channarayapatna Kishan, MD
Editor: Eugene S. Smith, III, MD

Fig. 1 : A granular appearance of the myocardium suggests an infiltrative process.

Most heart failure is due to hyperten -
sfon or coronary artery disease. Other
causes are possible, and the clinician must
always be alert to etiologies that are po-
tentially reversible. This case describes a
patient with probable hemochromatosis
identified at the time of presentation with
congestive heart failure .

Case Presentation

Mr. RF is a 50-year-old white male
with recently diagnosed type II diabetes
mellitus requiring insulin; liver disease
with thrombocytopenia related to his
heavy alcoholism; and hepatitis B and C,
presented to the emergency room with
palpitations, chest discomfort and shortness
of breath. Patient had noted generalized
weakness and fatigue, unrecommended
weight loss and abdominal discomfort with
increased abdominal girth. His review of
systems was significantly positive for or-
thopnea, paroxysmal nocturnal dyspnea,
decreased libido and easy bruisability.

He reported a history of heavy alco-
hol use and intravenous drug ex-use; he
denied any use of over-the-counter
supplements, no history of blood transfu-
sions and no family history of liver dis-
ease. On initial exam the patient was in
moderate distress with a blood pressure
of 108/76 mm/Hg, pulse rate 180 per
minute (irregular initially). Neurological
exam was non-focal with peripheral neu-
ropathy; the chest was clear.

The cardiac exam demonstrated an
irregularly irregular rhythm, a grade II/
VI systolic murmur heard best over the
apex with radiation to the axilla and a
laterally displaced apical impulse. The
abdomen was distended with a moder-

ate amount of ascites and hepatomegaly;
lower extremities showed trace edema,
and his skin was tan colored. Initial
laboratory results revealed a platelet
count of 47,000 (per mm3), a white
blood cell count of 3,490 (per mm3),
with a normal differential and his he-
matocrit was 42.6%. Electrolytes and
kidney functions were normal; INR was
1.4 and thyroid stimulating hormone
measured 2.8 (pU/L. Electrocardiogram
demonstrated atrial fibrillation with
rapid ventricular response. He con-
verted to normal sinus rhythm after one
dose of diltiazem intravenously.

One physician noticed his skin color
and suspected a possible iron overload
disorder. Iron studies revealed serum
iron of 214 mg/dl (normal range 52 to

183), a total iron binding capacity of
241 mg/dl (normal range 265 to 430), a
ferritin of 624 ng/ml (normal range 42
to 262) and a transferrin saturation of
89% (normal range 22 to 46). A liver
biopsy was recommended but was re-
fused by the patient; genetic testing for
known mutations of the HFE gene was
negative. An echocardiogram showed
concentric left ventricular hypertrophy,
four chamber dilatation, global hypoki-
nesis, trace aortic regurgitation, mild to
moderate mitral and tricuspid regurgi-
tation and an ejection fraction of 25-
30%. A granular appearance of the myo-
cardium suggested an infiltrative process
(Figure 1).

The patient received treatment for
his systolic dysfunction. Cardiac mag-

24 • The Journal

Volume 97

netic resonance imaging was scheduled
as an outpatient to confirm the diagno-
sis of hemachromatosis (HC). Despite
education describing the importance of
initializing treatment and screening of
other family members, he failed to re-
turn for follow-up.

Discussion

Iron loading resulting in organ dam-
age was recognized over 100 years ago. It
was first described in 1865 by Trousseau
and named by Van Recklinghausen in
1889.1 The most common cause of iron
loading is hereditary hemochromatosis,
which is caused by a missense mutation
in the HFE gene on chromosome num-
ber 6 and was recently identified by Feder,
et al. in 1996. 2 Other causes such as
thalassemia, sideroblastic anemia, recur-
rent blood transfusions, alcoholic cirrho-
sis, porphyria cutanea tarda and congeni-
tal atransferrinemia also are described.

Although iron overload is much less
common than iron deficiency, its early
diagnosis and treatment are still crucial
because of the reversible and possible fa-
tal effects on major organs, particularly
the heart. Hemachromatosis is thought
to have a selective advantage in an era
when dietary iron was relatively scarce.
However, the 20th century has been ac-
companied by an increased meat con-
sumption and an increased life expect-
ancy, therefore, hemachromatosis is a
prominent disease and no longer advan-
tageous.3 The prevalence of HC is about

0.3% with a carrier state in up to 10% of
the European population. Factors such
as dietary iron intake or regular blood
loss such as menstruation modifies its
clinical expression. It is therefore five to
10 times more frequent in males than fe-
males.4 Membrane damage through lipid
peroxidation and promotion of increased
collagen synthesis are the most accept-
able theories for pathogenesis of iron- in-
duced organ damage.5

Non-Cardiac Manifestations
of Hemochromatosis

Symptoms usually develop in the
fourth-sixth decade, occurring 10 or more
years later in women. Early symptoms are
usually non-specific such as fatigue, weak-
ness, weight loss, abdominal or joint pain,
loss of libido, impotence and infertility.
The characteristic clinical signs of HC in-

clude diabetes mellitus, skin hyperpigmen-
tation and liver disease.

Cardiac Manifestations

ECG and echocardiographic changes
secondary to myocardial iron loading pre-
cede symptoms. The most common car-
diac complications are congestive heart
failure and cardiac arrhythmias, which are
the presenting manifestations in 5%-15%
of symptomatic patients. The most com-
mon cardiac arrhythmias are ventricular
because of higher iron deposition, but su-
praventricular arrhythmias and atrioven-
tricular blocks also are noted. The SA
node is affected less often and has been
demonstrated both clinically and histo-
logically.6,7 The effect of iron loading on
coronary arteries is controversial. Some
studies suggest promotion of atheroscle-
rosis by enhancing the oxidation of LDL
(a critical step in developing atheroscle-
rosis), while other studies describe it as
an independent factor.8

Diagnosis

Hemochromatosis is diagnosed by
clinical suspicion, screening blood tests,
genetic testing and liver biopsy. Defini-
tive diagnosis of cardiac involvement
with iron loading is very challenging and
must exclude other etiologies such as is-
chemic heart disease or long-standing
hypertension. Echocardiographic
changes are not very sensitive but usu-
ally reveal features of dilated cardiomy-
opathy and global systolic dysfunction.
The deposition of iron interferes with
myocardial relaxation leading to dias-
tolic dysfunction.9,10 Endomyocardial
biopsy has a low yield since the deposi-
tion of iron may be focal.11 MRI also has
been used since iron disturbs the mag-
netic field homogeneity; the degree of
signal alteration is related to the intrin-
sic tissue iron levels.10

Treatment

Life-long phlebotomy is required in
patients with genetic hemochromatosis
with follow-up of total body iron and
ferritin levels. Chelation therapy also is
used in patients with secondary iron
overload.

Prognosis

Early diagnosis and treatment may
allow reversal of organ damage and re-

store normal life expectancy. The
amount of iron deposition in the myo-
cardium, which can be estimated by
MRI, is considered a prognostic factor.

Conclusion

Iron overload is an important cause
for reversible cardiac disease; therefore,
high clinical suspicion is required for
early diagnosis and treatment. Newer
diagnostic techniques may assist early
detection especially if applied to pa-
tients in high-risk groups. ■

References

1. Worwood M. Hemochromatosis:
pathological or beneficial. Dept of
Haematology, University of Wales
College of Medicine 1998: 1925-1933.

2. Crawford D, et al. Hemochromatosis.
Bailliere’s Clinical Gastroenterology
1998; Vol 12, No. 2: 209-225.

3. Andrews N, Levy J. Blood. The Jour-
nal of the Am. Soc. of Hematology
Sept 1998; Vol 92, No 6: 1845-1851.

4. Harrison S. Textbook of Internal
Medicine. PP. 2149-2152.

5. Hauser S. Hemochromatosis and the
Heart. Heart disease and Stroke 1993;
Vol 2: 487-489.

6. Wang TL, et al. Sick Sinus Syndrome
as the Early Manifestation of Cardiac
Hemochromatosis. Journal of Electro-
radiology 1994; Vol 27, No 1: 91-96.

7. Rosenquist M, Hultcrantz R. Preva-
lence of a haemochromation among men
with clinically significant Brady
arrhythmias. European Heart Journal
1998; Vol 10: 473-478.

8. Miller M, Hutchins G. Hemochroma-
tosis, Multi-organ Hemosiderosis, and
Coronary Artery Disease. JAMA, July
1994; Vol 272, No 3: 231-233.

9. Click R, et al. Echocardiography
and Systemic Diseases. J. Am. Soc.
Echo 1994; Vol 7:201-216.

10. Liu P, Olivieri N. Iron Overload Car-
diomyopathies: New insights into an
old disease. Cardiovascular Drugs and
Therapy 1994; Vol 8: 101-110.

1 1 . Scully R, et al. Case Records of the
Massachusetts General Hospital.
NEJM, August 1994; 460-466.

Drs. Kazzaz, Kishan and Smith work
in the department of internal medicine,
DAMS Medical Center and the John L.
McClellan Memorial Veterans Hospital.
Drs. Kishan and Smith serve in the division
of cardiology.

Number 1

June 2000 • 25

GHMHfl KHIFE BHDIOSUHGEBY:

Brain Surgenj Without a Scalpel

The Gamma Knife Radiosurgery Center, now
in full operation at LIAMS, is a revolutionary
noninvasive tool used to treat intracranial benign
and malignant tumors, vascular malformations
and certain functional disorders such as trigeminal
neuralgia without a single incision. The Gamma
Knife uses a concentrated radiation dose from
Cobalt-60 sources to damage abnormal tissue
while sparing adjacent normal tissue. This
exactness is accomplished by 201 beams of

radiation intersecting to form a precise tool.
These beams are focused on the target area
destroying only that which is abnormal, while
sparing adjacent, normal tissue from clinically
significant radiation.

Treatment with the Gamma Knife is
multidisciplinary. The skills of a neurosurgeon,
radiation oncologist and physicist are brought
together to develop a treatment program tailored
to each individual patient.

SAFE

The risk of surgical complications is greatly reduced because the Gamma Knife procedure is performed without
an incision. Therefore, Gamma Knife radiosurgery is virtually painless. Patients routinely use only a local anesthesia
with a mild sedative, thereby eliminating the problems sometimes associated with general anesthesia.

COST SRUIHG

Conventional neurosurgery typically means a lengthy hospital stay, expensive medication and sometimes
months of rehabilitation. The Gamma Knife reduces these costs greatly. Patients are usually able to leave the
hospital the same day and resume their normal activities within a few days. Post-surgical disability and convalescent
costs are typically minimal. At the same time, it provides patients with dramatically improved quality of life by
avoiding post-operative complications such as hemorrhage and infection associated with conventional surgery,
m

The success rate of the Gamma Knife is unprecedented. It has established clinical efficacy for many reported
indications including obliteration rates in AVM's, and treatment success rates for acoustic neuromas, meningiomas
and metastatic tumors. Close to 1 35,000 patients have had Gamma Knife radiosurgery with no mortality and minimal
morbidity reported. Backed by over three decades of clinical experience and documented results. No other neurosurgi-
cal tool has met with such impressive results.

For more information on the (JAMS Gamma Knife Center call Mark E.

Linskey, M.D., Co-Director, Neurosurgery or Dennis Shrieve, M.D., Ph.D.,

Co-Director, Radiation-Oncology at 501 /601-1 800 or 1-800-942-8267.

UAMS

MEDICAL

CENTER

World Class Care

UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
4301 West Markham / Little Rock, Arkansas 72205
www. gammaknife.uams.edu

SPECIAL ARTICLE

Preventing Perinatal HIV: Prenatal HIV Testing
and Strategies to Reduce the Risk of Maternal —

Fetal HIV Transmission

By Michael Saccente, MD

Number 1

June 2000

The transmission of human immunodeficiency virus
(HIV) from infected mothers to their infants has declined
dramatically over the past several years in the United
States.1, 2 This favorable trend followed widespread imple-
mentation of the three-part zidovudine (ZDV, AZT) regi-
men evaluated in Pediatric AIDS Clinical Trials Group
Protocol 076 (PACTG 076), which reduced the risk of
maternal — infant transmission hy nearly 70%. 3

Obviously, measures directed at preventing perinatal
transmission are not considered unless the pregnant woman
is known to be HIV-infected. With this in mind, the U.S.
Public Health Service (USPHS) recommended voluntary
prenatal HIV testing and counseling in 1995. 4 This article
reviews the rationale behind these recommendations with
the goal of reminding health care providers about the ben-
efits of prenatal HIV testing. Strategies used to reduce the
risk of perinatal HIV transmission are summarized.

HIV/AIDS in Women

As of Sept. 30, 1999, HIV (including AIDS) was re-
ported in 4,529 Arkansans since 1983. Females comprise
19% of this total, and since 1995, females have accounted
for approximately 23% of reported cases of HIV (includ-
ing AIDS). The vast majority of cases occur among women
of childbearing age, and heterosexual contact is the pre-
dominant transmission risk category for women. Black
women are disproportionally affected; while only 16% of
women in Arkansas are black, 57% of adult and adoles-

cent women with HIV (not AIDS) reported between 1995-
1997 were black.

The epidemiology of HIV and AIDS among women in
Arkansas resembles the national picture. Women accounted
for 19% of the adult AIDS cases reported in the United
States in 1995, and 57% of these women were black."

Nationwide, HIV infection rates continue to rise among
women of childbearing age, particularly adolescent racial mi-
norities.6 Compared to 1991 rates, the greatest increases in
AIDS incidence rates in 1995 occurred among women re-
siding in the midwestern and southern regions of the United
States.5

TVends in Perinatal HIV/AIDS

In the United States, perinatal AIDS cases peaked in
1992 (n=907), and subsequently decreased 67% between
1992-1997 (n=297)d

Although declining
birth rates among
HIV-infected
women have
contributed
to this fa-
vorable
trend,
most of
the

duction in the incidence of perinatal
AIDS is attributable to other factors,
the most important of which is mater-
nal antiretroviral therapy.

From 1992-1997, a total of 135 in-
fants were bom to HIV- infected women
in Arkansas. Seventy-three perinatally
exposed infants were born during the
1995-1997 period, an increase of 20%
compared to the 1992-1994 period.
Among the total 135 exposed infants,
81 (60%) are not infected with HIV, 6
(4%) have asymptomatic HIV infec-
tion, 17 (13%) have AIDS, and 31
(23%) have been lost to follow-up or
moved out of state.

Reducing the Risk of Maternal-
Fetal Transmission of HIV

The strongest predictor of HIV
transmission from mother to infant is
the maternal plasma HIV RNA level.
7, 8, 9, io The USPHS recommends that
the same general parameters used in the
management of nonpregnant HIV- in-
fected patients should be applied to
pregnant women.11 In other words, one
goal of antiretroviral therapy during
pregnancy is sustained maximal sup-
pression of the plasma HIV RNA level.
Antiretroviral regimens used for preg-
nant women should include ZDV. In
addition to antepartum antiretroviral
therapy, intravenous ZDV is given dur-
ing labor.12

Pregnant women who present for
the first time late in pregnancy or in
labor should be tested for HIV. Women
found to be infected before delivery
should receive a ZDV containing
antiretroviral regimen. This approach,
though not optimal, is supported by
data that suggest that courses of ZDV
shorter in duration than that used in
PACTG 076 reduce the rate of trans-
mission.13

Other strategies that target intrau-
terine and intrapartum transmission
include limiting exposure of the in-
fant to maternal blood and secretions
(e.g. with cesarean section), treating
conditions that might facilitate trans-
mission and prophylactic
antiretroviral therapy for the infant.14

Currently, only the last strategy
can be recommended universally as a
means to reduce maternal-fetal trans-

mission of HIV. Avoidance of
breastfeeding reduces postpartum
transmission.14

Potential Benefits
of Prenatal HIV Screening

In addition to providing the oppor-
tunity to interrupt perinatal transmis-
sion, prenatal HIV testing allows for the
early identification and treatment of
infected infants. Of course, women
found to be HIV-infected may benefit
from earlier treatment of their disease
than would otherwise occur if they were
not screened.

Prenatal HIV Testing and
Reporting in Arkansas

Arkansas law requires that every
physician or other health care provider
who attends pregnant women test each
woman for HIV, syphilis and hepatitis
. B virus and provide counseling regard-
ing the risks of transmission of these
infections to her infant. If a patient re-
fuses testing, this circumstance must be
documented in the medical record.
HIV is a reportable disease in Arkan-
sas. When HIV infection is diagnosed
in a pregnant woman, the health care
provider has two options for reporting
the case to the Arkansas Department
of Health. The HIV/AIDS Case Report
Form may be completed and sent to
Jerry Mulloy, Pediatric Officer, 4815 W.
Markham, Slot 33, Little Rock, AR
72205, or Mulloy may be called directly
at (501) 661-2908. ■

References

1. Lindegren ML, Byers RH, Thomas P,
et al. Trends in perinatal transmission
of HIV/AIDS in the United States.
JAMA 1999;282:531-8.

2. CDC. Update: perinatally acquired
HIV/AIDS - United States, 1997.
MMWR 1997;46:1086-1092.

3. Connor EM, Sperling RS, Gelber R,
et al. Reduction of maternal - infant
transmission of human immunodefi-
ciency virus type 1 with zidovudine
treatment. N Engl J Med 1994; 331:
1173-80.

4. CDC. U.S. Public Health Service rec-
ommendations for human immuno-
deficiency vims counseling and volun-
tary testing for pregnant women.

MMWR 1995;44(no. RR - 7).

5. Wortley PM, Fleming PL. AIDS in
women in the United States.

JAMA 1997;278:911-6.

6. Mofenson LM. Can perinatal HIV
infection be eliminated in theUnited
States? JAMA 1999;282:577-9.

7. Dickover RE, Garratty EM, Herman
SA, et al. Identification of levels of
maternal HIV - 1 RNA associated
with risk of perinatal transmission - ef-
fect of maternal zidovudine treatment on
viral load. JAMA 1996;275:599 -605.

8. Sperling RS, Shapiro DE, Coombs
RW, et al. Maternal viral load, zido-
vudine treatment, and the risk of trans-
mission of human immunodeficiency
vims type 1 from mother to infant. N
Engl J Medl996;335:1621-9.

9. Mofenson LM, Lambert JS, Stiehm
ER, et al. Risk factors for perinatal
transmission of human immunode-
ficiency vims type 1 in women
treated with zidovudine. N Engl J
Med 1999;341:385-93.

10. Garcia PM, Kalish LA, Pitt J, et al.
Maternal levels of plasma human
immunodeficiency vims type 1 RNA
and the risk of perinatal transmission.
N Engl J Med 1999;341:394-402.

1 1 . CDC. Public Health Service Task
Force recommendations for the use
of antiretroviral drugs in pregnant
women infected with HIV - 1 for ma-
ternal health and for reducing perina-
tal HIV - 1 transmission in the United
States. MMWR 1998;47(no. RR-2).

12. CDC. Recommendations of the U.S.
Public Health Service Task Force on
the use of zidovudine to reduce peri-
natal transmission of human immuno-
deficiency vims. MMWR 1994;43(no.
RR-11).

1 3 . Shaffer N , Chuachoowong R, Mock
PA, et al. Short - course zidovudine for
perinatal HIV-1 transmission in
Bangkok, Thailand: a randomised con-
trolled trial. Lancet 1999;353:773-80.

14. Rogers MF, Shaffer N. Reducing the
risk of maternal - infant transmission
of HIV by attacking the vims. N Engl J
Med 1999;341:441-2.

Dr. Saccente is medical director for
the division of AIDS/STD at the Ar-
kansas Department of Health and assis-
tant professor of medicine in the division
of infectious diseases at the University of
Arkansas for Medical Sciences.

28 • The Journal

Volume 97

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PEOPLE+EVENTS

HONORED

Physicians Receive
Awards from AMA

Each month the
American Medical
Association presents the
Physician’s Recognition
Award to those who have
completed acceptable
programs of continuing
education.

AMA recipients for
January include Drs.
Edward E.C. Angtuaco,
Robert L. Fincher, Robert
B. Kennedy, Robert L.
Overacre and Carl V.
Smith, all of Little Rock;
Dr. Charles W. Craft of
Greenwood; Dr.
Theophilus A. Feild of
Fort Smith; Dr. Thomas
A. Langston of Harrison;
Dr. Phuong C. Ly of
Marianna; and Dr. Martha
K. Morgan of Pea Ridge.

OBITUARY

John D. Ashley Jr., MD

Dr. John D. Ashley,

84, of Newport, a retired
internal medicine physi-
cian, died Feb. 22. Dr.
Ashley graduated from
Virginia Commonwealth
University in Richmond
in 1940. He became board
certified in internal
medicine in 1947 and was
licensed to practice
medicine in Arkansas in
1949.

Dr. Joseph M. Beck II, center, at the March awards dinner at the AMA National Leadership
Development Conference in Miami.

Dr. Beck Completes Leadership Program

Dr. Joseph M. Beck II of Little

Rock was one of 50 physicians selected
to participate in the American Medical
Association/Glaxo Wellcome Emerging
Leadership Program at the AM As Na-
tional Leadership Development Confer-
ence March 26-28 in Miami. Dr. Beck
is board certified in internal medicine
and medical oncology.

The 50 practicing physicians at-
tended a day-long, invitation-only pro-

gram, sponsored by Glaxo Wellcome,
at the Fountainebleau Hilton Hotel.
The leadership program is an intensive
leadership development program em-
phasizing legislative advocacy. Those
selected are generally in their early to
mid-careers, have been in practice two
years and have demonstrated leadership
potential, commitment to leadership,
participation in organized medicine and
diversity of leadership experience.

Noor Kabani, MD

Specialty: 1M
1609 W. 40th Ave., #207
Pine Bluff, AR 71603
(870) 534-7585

New Members

Mark Malloy, MD

Specialty: 1M
909 Unity Road
Crossett, AR 71635
(870) 364-9111

James Lee Krupala, MD

Specialty: OTO
1408 W. 43rd Ave.

Pine Bluff, AR 71603
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Christopher A. Lamps, MD

Specialty: Resident - CHP
1120 Marshall St., #654
Little Rock, AR 72202
(501) 320-5150

Richard Nelson, MD

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Port Smith, AR 72913
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Zbigtniew Kula, MD

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Specialty: P
21 Bridgeway

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Steven S. Orten, MD

Specialty: OTO
6801 Rogers Ave.

Port Smith, AR 72913
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Number 1

June 2000 • 31

When we focused
on heart care, the world
focused on us.

They come here to see. And to learn. Heart specialists
from places as far away as Poland, Germany, Taiwan,
and Japan. And from cities around the country.
They represent prestigious universities. And leading
healthcare systems. They are physicians and researchers
and hospital managers, the best the world has to offer.
Yet they come to our hospital to see our facilities, our
technologies, and to understand our procedures. Why?
To learn how to be even better. If your patients had
heart disease, could they come here too?

Arkansas Heart Hospital

An entire hospital fighting heart disease
1701 S. Shackleford Road • (501) 219-7000 • www.arheart.com

Vijayabhasker Reddy, MO

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Melanie Smith, MD

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North Little Rock, AR 72116
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Steven 0. Smith, MD

Specialty: ORS
P.O. Box 17027
Fort Smith, AR 72917
(501) 709-7002

William S. Sosebee, MD

Specialty: OBG
101 Skyline Drive
Russellville, AR 72801
(501) 968-2345

Pattana Srinivasan, MD

Specialty: Resident - AN
4301 W. Markham St.

Little Rock, AR 72205
(501) 686-6114

R. Todd Stewart, MD

Specialty: IM
6801 Rogers Ave.

Fort Smith, AR 72903
(501) 452-2077

Michael D. Stout, MD

Specialty: FP

4202 S. University Ave.

Little Rock, AR 72204
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Sachin Swarup, MD

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510 Ondo Lane, #7D
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P.O. Box 246
Crossett, AR 71635
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James D. Waters, MD

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620 N. Willow St.

Harrison, AR 72601
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32 • The Journal

Volume 97

ADVERTISERS INDEX

AMS Benefits Inc Inside back cover

Arkansas Financial Group Inc., The 4

Arkansas Foundation for Medical Care 3

Arkansas Heart Hospital 32

Employers Healthcare Resources Inc 9

Flake and Kelley Management 8

Freemyer Collection System 15

Gary Darwin, MD 9

Guest House Inn 14

Helena Regional Medical Center 22

Hutchinson/Ifrah Financial Services Inc 17

Jones Daewoo of Arkansas 18

Little Rock Medical Association 14

Maggio Law Firm 30

Medical Center of South Arkansas 20

Medicus 13

Metropolitan National Bank 22

Millard'Henry Clinic 13

PhyAmerica Physician Services Inc 20

QualChoice/QCA of Arkansas 29

Riverside Motors 6

St. Bernards Regional Medical Center 12

St. Paul Medical Services 21

Snell Prosthetic & Orthotic Laboratory 10

Southwest Capital Management Inc 13

Southwestern Bell Wireless Inside front cover

State Volunteer Mutual Insurance Co Back cover

University of Arkansas for Medical Sciences 26

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Cardholder’s name:

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_Exp. date:

Cardholder’s Signature:,

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Zip:_

Telephone: ( )

Fax No.: ( )

Call the AMS office at 501-224-8967 or 800-542-1058 for volume discount pricing

CREDIT CARD ORDERS
CAN BE FAXED TO:
(501) 224-6489

Number 1

June 2000 • 33

ARKANSAS RETREATS

Ri HELENS HI

Top, left , Helena’s Delta Cultural Center recently reopened with new exhibits. Top, right, the Confederate cemetery appeals to history
buffs. Bottom, the King Biscuit Blues Festival brings thousands to the town each October.

Foxglove Bed and Breakfast

Revisit the turn of the century with a visit to the elegant Foxglove Bed and Breakfast in
Helena.

The stunning mansion, built in 1900 by Elmer West and listed on the National Regis-
ter of Historic Places, hunkers down on Crowley’s Ridge overlooking the mighty Missis-
sippi River and historic Helena. The home looks much as it did in its glory days — period
antiques, parqueted floors, stained glass, fine oriental rugs, six original fireplaces, quarter-
sawn oak and a double-seated staircase. But modern conveniences, namely private luxury
baths and whirlpool tubs, give the B&B an added bonus of opulence. The home was largely
unchanged until 1944 when conversion into a bed and breakfast was undertaken. Today it
offers eight guest rooms.

Every visitor can find something entertaining in Helena, which is a Civil War battle
site. Foxglove is within three miles of two casinos, and 10 more lie between Helena and
Memphis, which is a short 60 miles north and home to Graceland, Elvis’ palatial spread.
Antiques shops are plentiful, as are historical sites, including the Phillips County Library
and Museum and Confederate cemeteries. In May, the Delta Cultural Center reopened
with new exhibits. Every October, Helena hosts the annual King Biscuit Blues Festival, the
third largest blues festival in the world.

For more information about the Foxglove, contact John Butkiewicz, innkeeper, at 220
Beech St., Helena, 72342, (870) 338-9391 or (800) 863-1926. You can also visit the B & B
on line at www.bbonline.com/ar/foxglove. ■

34 • The Journal

Volume 97

Photos: A.C. Haralson/ Arkansas Department of Parks & Tourism

AMS BENEFITS, INC.

A wholly owned subsidiary of the
Arkansas Medical Society
P. O. Box 55088

•’ Little Rock, Arkansas 72215-5088
(501)224-8967
WATS 1-800-542-1058 '

FAX (501) 224-6489
Ask about our other services including
Professional Overhead, Disability

- ' & Life Insurance.

The Arkansas Medical Society Health Benefit.Program is a health insurance plan^designed exciusi
members of the Arkansas Medical Society. Underwritten by American Investors Life Insurance Con
Indemnity and managed care plans available. For information call (501) 224-8967 or 1-800-542-105S

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40 • The Journal

Volume 97

Volume 97 Number 2
July/August 2000

OF THE ARKANSAS MEDICAL SOCIETY

Winner of the ASAE Excellence in Communications Award

Annual Session Special Issue

CONTENTS

FEATURES

46 AMS Annual Session Highlights

A look at the stellar line-up of speakers from this year's
meeting, plus pictures to commemorate the event.

52 A Look Back

1 999 was a banner year for the AMS , with the creation of
a Long-range Planning Committee, set to help refocus the
AMS’ efforts over the next several years.

55 Shuffield Award Winner

Rep. Marion Berry, D-Ark. , is this year’s winner of an
award given to nonphysicians making a difference in the
state’s health care sector.

56 Fifty Year Club

57 Alliance Report

Cynthia Weber is the Alliance’s new president.

59 Report of the Council

61 Report of the House of Delegates

62 Long-range Planning Committee Report

63 Long-range Planning Committee Plan
65 Annual Session Sponsors

68 AMS 2000-2001 Officers

DEPARTMENTS

45 Letters to the Editor

45 What We’ve Done For You Lately

66 People + Events

Dr. Gerald Stolz assumed leadership
of the AMS .

— page 5 1

U.S. Rep. Marion Berry was named
this year’s Shuffield Award winner.

— page 55

Number 2

July/August 2000 • 41

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COMMUNICATIONS COORDINATOR

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EXECUTIVE VICE PRESIDENT

Kenneth LaMastus, CAE

ASSISTANT EXECUTIVE VICE PRESIDENT

David Wroten

EDITORIAL BOARD

Jerry Byrum, MD
Joseph M. Beck, II, MD
Lee Abel, MD
Samuel Landrum, MD
Jerry Kendall, MD
William Ackerman, MD

Pediatrics
Oncology
Internal Medicine
Surgery
Family Practice
Anesthesiology

EDITOR EMERITUS

Alfred Kahn Jr., MD

ARKANSAS MEDICAL SOCIETY
2000-2001 OFFICERS

Gerald A. Stolz, Jr., MD, Russellville
President

Joe Stallings, MD, Jonesboro
President-elect

Paul A. Wallick, MD, Monticello
Vice President

Lloyd G. Langston, MD, Pine Bluff
Immediate Past President

CarltonL. Chambers, III, MD, Harrison/Little Rock
Secretary

Dwight M. Williams, MD, Paragould
Treasurer

Anna Redman, MD, Pine Bluff
Speaker, House of Delegates

Kevin Beavers, MD, Russellville
Vice Speaker, House of Delegates

Joseph M. Beck, II, MD, Little Rock
Chairman of the Council

Established 1890. Owned and edited by the Ar-
kansas Medical Society and published under the di-
rection of the Council.

Advertising Information: Contact Stephanie
Hopkins, P.O. Box 3686, Little Rock, AR 72203;
(501) 372-2816.

Postmaster: Send address changes to: The Journal
of the Arkansas Medical Society, P. O. Box 55088,
Little Rock, Arkansas 72215-5088.

Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.

The Journal of the Arkansas Medical Society
( ISSN 0004- 1 858) is published monthly by the Arkan-
sas Medical Society, #10 Corporate Hill Drive, Suite
300, Little Rock, Arkansas 72205 . Printed by The Ovid
Bell Press, Inc., Fulton, Missouri 65251. Periodicals
postage is paid at Little Rock, Arkansas, and at addi-
tional mailing offices.

Articles and advertisements published in The Jour-
nal are for the interest of its readers and do not
represent the official position or endorsement of The
Journal or the Arkansas Medical Society. The Journal
reserves the right to make the final decision on all
content and advertisements.

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Let Us Hear From You!

You can now E-mail AMS
at the following addresses:

Main address: ams@arkmed.org
Ken LaMastus: klamastus@arkmed.org
Lynn Zeno: zeno@arkmed.org

David Wroten: dwroten@arkmed.org
Kay Waldo: kwaldo@arkmed.org

Journal: joumal@arkmed.org

Plus. . .

We now have a web site.
Come visit us soon at:
www.arkmed.org

Number 2

July/August 2000 • 43

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44 • The Journal

Volume 97

WHAT WE’VE DONE FOR YOU LATELY

House Adopts
Action Plan for Future

By David Wroten

LETTERS

I read with interest the com-
mentary by Dr. Jerry D. Byrum in
the May issue of the Medical Jour-
nal. I think he expressed well the
many problems that exist today in
the use of technology and the vari-
ous ways that it touches the physi-
cian in the active practice of medi-
cine. I also share his concern that
the communication that existed
formally between physicians and
the camaraderie that was often
found around the “coffee table” is
no longer evident, which may be
good but certainly is a departure
from the past.

The communication that he did
not touch upon is the one that I hear
most neglected. The complaint that
seems to emanate between physi-
cians and patients is that the doctor
“used no words with me,” “he com-
municated very little,” “spent very
little time with me” and “I can’t get
anyone to speak to me over the tele-
phone regarding my problem.”

Hopefully, the many electronic
devices that are present today may
eventually be used for better com-
munication between physicians
and patients. All of these innova-
tions are wonderful but there is
nothing yet comparable to the phy-
sician conversing with the patient
face to face, and physicians taking
time to spend with his colleagues
or referring physician.

W. Ray Jouett, MD
Medical Director,

National Comp. Care Inc.

Submit letters to the editor to
iournal@arkmed.org or by faxing
(501) 224-6489.

The full text of the AMS Long-range
plan adopted in May by the House of
Delegates can be found on page 63 of
this issue of The Journal. I urge you to study
it carefully and look for ways YOU can
become involved in carrying out its ac-
tion plans.

The plan represents the work of more
than 100 physicians during the past year.
Throughout all of the meetings and dis-
cussions there were several major issues
or themes that penneated the room —
technology, communication, membership
and governance.

Technology

If you are not on the information su-
perhighway, prepare to get left behind
— way, way behind. It is not too late to
jump on but time is running out. The
challenge for the AMS is to maximize
the use of Internet-based technology
while not ignoring the needs of our
members who have yet to embrace its
use. Look for major improvements in the
AMS web page, including a members
only section, online registration, bulle-
tin boards and online access to continu-
ing medical education.

Communication

The most profound observation to
come from the past years efforts is the need
to improve AMS communication strate-
gies, mostly between the AMS and its
membership. The Society publishes news-
letters, alerts, this journal and other tar-
geted material on a regular basis. Staff and
physician leaders are frequent speakers at
county medical societies and state spe-
cialty society meetings. Yet, throughout
the planning process, volunteers made
suggestions for proposed activities only to
find out that the AMS was already doing
them. The message of what the AMS does
is not getting out to the membership ef-
fectively.

As a result, a special task force will
be appointed to recommend improved
communication strategies. How can
members appreciate the value of their

Society if they don’t know what it is we
do? We must change this.

Membership

The lifeblood of any organization is its
membership. The AMS has a strong mem-
bership base. However, we must respond
more rapidly to the changing demograph-
ics of the physician community. Generation
Xers are driven by different values and wants
than baby boomers. Employed physicians
have different needs than physicians who
own their practices. Fifty percent of medi-
cal students are women. These changes must
be recognized, and the AMS must be will-
ing and able to make changes to ensure that
all physicians realize the value and benefit
of their Society. A new membership com-
mittee will be developed to guide the AMS
response to this challenge.

Governance

The organizational structure of the
AMS was developed during a time when
the county medical society was the focal
point of physician involvement and lead-
ership. Times have certainly changed. You
can count the active county medical soci-
eties on one hand. There must be avenues
and opportunities for physicians to develop
their leadership skills (as opposed to their
medical skills). The AMS must ensure that
these opportunities and avenues are avail-
able to physicians to provide for future lead-
ers of the Society. As old avenues close,
new ones must open. The AMS will ap-
point a task force to review the current
avenues of participation and recommend
changes to meet the needs of today’s envi-
ronment.

The message is simple. The AMS ex-
ists for one reason and that is to represent
the physicians of Arkansas. Tire mission as
stated in the long-range plan says it very
succinctly — to serve as the voice of Ar-
kansas physicians. The groundwork has
been done by 100 of your colleagues. Your
elected leaders and staff will work tirelessly
to make sure the mission is achieved. Maybe
it’s time you stepped forward and said, “I’m
proud to be a physician, how can I help?”B

Number 2

July/August 2000 • 45

2000 Arkansas Medical Society

Annual Session

Clockwise from top left, Dr. James Sheridan, left, ofPiggott won the $1 ,000 travel certificate from AMS given
away at the annual meeting. Dr. Lloyd Langston, AMS 1 999-2000 president, inducts AMS’ new president, Dr.
Gerald Stolz. Dr. Joe Stallings is congratulated on his new president-elect position. The expo of sponsors was
a highlight for AMS members at this year's meeting. Dr. Lloyd Langston, past president, Glenda
jSBlIteSu Langston, Judy Stolz and Dr. Gerald Stolz, president.

Learning from the Experts

Professionals Address Current Issues at AMS Session

By Judith M.Gallman

The educational portion of the
2000 Annual Session covered topical
issues covering broad territory.

Subjects included medical discov -
eries in space, gene therapy, joining a
group practice or partnership , overuse
of antibiotics , handling weapons of
mass destruction and applying the
Internet to health care.

The meeting was in Little Rock
on May 5 -6 at the Embassy Suites
Hotel. Here are highlights from
presenters who participated in the
session’s programs.

Onward to Online

Dr. Richard F. Corlin, speaker of
the House of Delegates for the Ameri-
can Medical Association and a gastro-
enterologist in
Santa Monica, Ca- ^

1 if . , spoke to the W

Delegates meeting 1

physicians about
how they can use S

the Internet to de- BJJf f|

liver efficient, qual- ]jr Qorlin
ity health care.

The U.S. health care sector is a
complicated industry but the Internet
is making that even more so. The lat-
est figures, Dr. Corlin said, indicate 68
percent of adult Americans get health
information online — two out of three
adults and growing. Of the 60 million
adults who used the Internet last year,
91 percent said they found the infor-
mation they wanted, he said.

With so many people online,
more patients are becoming better in-
formed about their health, but that
also means many are probably getting
harmful information posted by ama-
teurs, he said.

The easy way to solve this is to
have more physicians online provid-
ing information to patients. Some
physicians have been reserved about
computers in general, not to mention
the Internet. But there are good rea-
sons physicians should make the leap:

• More physicians and clinics are
coming online.

• The Internet is full of resources
that can help an individual or group
practice.

• With the Internet, physicians
can strengthen their relationships
with patients by channeling patients’
questions to their web site or by us-
ing their Internet-prompted ques-
tions to create better counseling and
treatment.

• Physicians need to be the man-
agers of health information online vs.
amateurs who are developing
dot. corns on a whim.

• It’s easy for physicians to make
the leap online because the AMA has
already taken the steps to maximize
patient care and minimize physicians’
learning curve.

The AMA, in conjunction with
Intel, has created the Internet Health
Roadshow, a basic training program
for physicians that has traveled to na-
tional and local AMA meetings and
has gotten rave reviews. Also, the
AMA’s web site at www.ama-assn.org
is easy to use and offers many re-
sources, including back issues of
JAMA and AMNews. And even
more important, the AMA and its
Online Oversight Panel have created
guidelines for physicians to use when
communicating with patients via e-
mail.

Another step in the right direc-
tion is Medem Inc., a consumer web
site created by the AMA and six na-
tional speciality societies. Medem
stands for “medical empowerment.”
The site offers peer-reviewed health
information for consumers. For phy-
sicians, it now offers “Put Your Prac-
tice Online,” which allows physicians
to create and publish a web site for
their practice. The seven organiza-
tions that started Medem are in dis-
cussions with 22 other speciality so-
cieties who want to be a part of this
new web site.

And for the issue of credibility
and authenticity on the web, the

AMA, along with Intel, has developed
“Digital Credentialing and Authenti-
cation Services.” Both groups have
identified a need for digital certificates
for physicians to ensure that patient
privacy and confidentiality are always
protected. This service will be sold to
health care-based Internet companies
interested in providing secure solu-
tions for their web sites. A digital cer-
tificate identifies individuals on the
Internet, providing a reliable tech-
nique to verify authenticity that is bet-
ter than a password or previously se-
cure Internet techniques.

With all these systems in place and
growing, physicians can be assured
that getting — and staying — on the
Internet can be secure, while enhanc-
ing office management and patient
care.

Space Traveler

Dr. M. Rhea Seddon, a general sur-
geon and chief medical officer of
Vanderbilt Medical Group in Nash'
ville, Tenn., is a former astronaut with
more than 722
hours in space on
three separate
space missions. She
is a former emer-
gency department
physician and a
former National
Aeronautics and
Space Administra-
tion advisor. In Little Rock, she spoke
about her NASA experiences, focus-
ing on the medical and life sciences
research she performed in space.

Dr. Seddon helped attendees un-
derstand how space experiences are
applicable in the disease process here
on earth.

Astronauts often experience an ac-
celerated form of osteoporosis, much
like the conditions present in the eld-
erly population, she said. They also
may develop a form of anemia, and a
lot of body systems — muscles, for in-
stance — quickly get out of shape in
the absence of gravity. The conditions

Dr. Seddon

Number 2

July/August 2000 • 47

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easily reverse once the astronauts are
back on the ground.

Space studies, she said, may some
day provide physicians with clues
about how the body adapts to certain
conditions, though more research is re-
quired. Research will be more useful
once a full-scale space station lab can
be permanently established, she said.
That way, researchers could test
whether treatment on earth will work
similarly in space.

Dr. Seddon said Arkansas physi-
cians were especially curious about and
interested in the everyday practice of
medicine and the use of equipment in
space. Simple procedures — CPR, for
instance — are infinitely more com-
plicated in weightless situations, she
said.

Before You Sign

James R Freiburg is a lawyer with
Weil Freiburg a Chicago-based general
practice law firm with an emphasis in
health care issues.
He offered advice
to young physicians
and others about
key points to keep
in mind when join-
ing a group practice
or partnership.

He said practi-
tioners should de-
termine what type of working environ-
ment they want, factoring in issues
such as geography and the type of prac-
tice — a private group, an institutional
employer such as a hospital or a teach-
ing and research center — in decision
making.

Those who opt for a private group
must decide whether a small group,
middle-sized group or large group is
preferable. In a small group, a new-
comer might be asked to join as an
owner immediately, possibly thrusting
the newcomer into a position of man-
agement very early. In mid-size firms,
the physicians may wonder whether
they’ll ever be an owner of the prac-
tice. In a large practice, it might take
years to meet all the partners.

“There’s nothing inherently good
or bad about any of this. The question
to answer is, ‘Where would I be the
happiest?’ ” Freiburg said.

He also urged physicians to visit

Freiburg

Volume 97

prospective employers and to decide
whether they’d like working in that
setting without considering compen-
sation.

“Compensation is an important
[consideration], but the first order of
business would be to make sure you
would enjoy working in that setting,”
he said.

Candidates should tour the
employer’s facility, inspect equipment,
look at other employees and quiz
younger physicians to see what they
think of the practice, Freiburg said.
Newcomers should tour the hospitals
where they’ll be rendering services and
take time to learn about the commu-
nity.

“When it does come time to talk
contract, use a check list,” Freiburg
said. “Make sure you cover everything
on the list.”

That list, Freiburg said, should
cover base compensation, bonus com-
pensation, scope of duties (including
the number of offices and hospitals
you may have to serve), the terms of
your employment (including call and
coverage issues), a moving allowance,
medical health insurance, continuing
medical education allowances, paid
time off and retirement plans.

Another key point, Freiburg said,
is to find out the likelihood of becom-
ing an owner or partner, including a
time frame, estimated cost and system
of payment.

And, finally, Freiburg said, care-
fully consider the restrictive covenant
provisions of the contract as well as
exceptions that may be built in that
might allow some relief from the re-
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About Antibiotics

Dr. Chesley Richards is a board-
certified internist and epidemiologist
with the Hospital Infections Program
at the Centers for
Disease Control.

He spoke in Little
Rock on the over-
use of antibiotics,
prescribing a 12-
step program for
more effective us-
age.

“The major
point we want to make is that antimi-
crobial resistance is a public health is-
sue,” Dr. Richards said. As antimicro-
bial resistance increases, there are
fewer effective agents available for
treating infection, he said.

But physicians can help remedy
the problem in several ways.

First, they should use all avail-
able vaccinations and immuniza-
tions so that patients won’t be as
susceptible to certain infections.
Also, doctors should strive to re-
move indwelling devices (urinary or
intravenous catheters) from pa-
tients as soon as possible, reducing
the risk of infection.

Physicians should be certain
they are really treating an infection.
Getting appropriate microbiological
cultures from outpatients or nursing
home patients is extremely difficult,
so appropriate interpretation is dif-
ficult. Occasionally cultures read
positive for bacteria but the bacteria
does not represent a real infection.

If a clinician determines an infec-
tion does exist, the clinician must treat
it as narrowly as possible. Treatment
includes educating patients to con-
tinue taking antibiotics for an appro-
priate treatment period so that the in-
fection is cured, surpassing the ten-
dency to stop when they feel better af-
ter a couple of days.

“We need to make rules, especially
in the hospital setting, that infectious
guidelines be used and patients be iso-
lated when appropriate,” Dr. Richards
said.

“And I think finally, most impor-
tant, is that we all — all heath care
professionals, nurses and interns, resi-
dents, doctors and pharmacists —
should wash our hands before seeing

50 • The Journal

Volume 97

Taking the Helm

Dr. Gerald Stolz Wants to Continue AMS’ Progress

At the AMS’ 1 24th Annual Session, Dr. Gerald Stolz Jr. , a Russellville
pathologist, was inducted as the 2000-2001 president. Here are a few
highlights from a recent interview with the new president.

Two of Dr.

Stolz’s goals: ad-
dressing the needs
of the new physi-
cians who are join-
ing the society’s
fold and making
sure that women
and minorities are
well represented in the society. He
hopes AMS’ older members will
assist him in encouraging young
physicians to join the society. Many
of these young physicians are join-
ing group practices and will need
an organization that is represent-
ing them, he said.

“We must respond to the needs
of younger physicians; they will de-
termine the future of the society.

“I want to reach out to women
and minority doctors, embrace
them and bring them into our
group as active, participating mem-
bers who know they have an im-
portant contribution to make to the
society.”

Dr. Stolz plans to watch the
wave of managed care in the state,
too.

“We do not have the critical
population masses outside of the
Little Rock area to let managed
care function the way it wants to
function. We are a very rural state,

and we don’t have
the critical popu-
lation masses out-
side of Little Rock
and northwest Ar-
kansas that capita-
tion will work in.

“I’m optimistic
about the future
for Arkansas physicians. I think we
will continue to see [preferred pro-
vider organizations] and other pay-
ers try to get more and more dis-
counted fees for services . . . but my
opinion is that managed care per
se is pretty well peaked in Arkan-
sas.”

While he’ll be busy with AMS
work, Dr. Stolz says he’ll make sure
to take time to relax. He and wife
Judy enjoy spending time near the
water at Greers Ferry Lake and
Captiva, a southwest Florida is-
land. The Stolzs also are big Arkan-
sas Razorback fans and often trek
to Fayetteville and Little Rock for
games.

“Captiva is really a well-kept
secret. It’s not crowded at all. The
beaches are beautiful, and it’s amaz-
ing the number of fine restaurants
that are crowded into that one
little area.

“I’m use to continuous travel.
It just comes with the territory.”

patients and after the patient contact
has occurred.”

Destructive Weapons
Assistance

Lt. Col. Richard Swan, director of
military support for the Arkansas Army
National Guard, enlightened AMS

Lt' col. Wi dioTti,ve Tterial

and biological weap-
ons and substances or chemical warfare.

Recently the federal government
has created teams whose duties are to
assist with the aftermath of mass de-
struction, Swan said. The highly
qualified teams, trained in specialty
areas of weapons of mass destruction,
will advise and assist the responders
who arrive first on such scenes. They’ll
be responsible for cleaning up after the
fact, much like the guard helps now
with natural disasters. The Arkansas
Army National Guard is in the pro-
cess of selecting its team, whose mem-
bers will be required to complete a
year of specialty training, Swan said.
Team members will understand how to
use a mobile analytical lab as well as a
unified command sweep. The first de-
vice will allow teams to identify “ev-
ery substance known to man” in an in-
stant, while the second device permits
contact via every imaginable commu-
nication spectrum, Swan said.

Gene Therapy

Dr. Nikhil Munshi, a research phy-
sician at the University of Arkansas
for Medical Sciences, spoke on gene
therapy at the an-
nual session. Dr.
Munshi has been
director and chief
of the Clinical
Gene Transduction
Laboratory at the
Molecular Oncol-
ogy and Gene
Therapy, Myeloma
and Transplantation Research Center
at UAMS since 1996.

Dr. Munshi has written many ar-
ticles on cancer treatment, investiga-
tional new drugs, virology, bone mar-
row transplantation and experimen-
tal hematology. He received his medi-
cal degree and residency training from

MS University in Baroda, India. He
was a fellow in oncology at Johns
Hopkins Oncology Center in Balti-
more and a fellow in hematology/on-
cology at Indiana University School
of Medicine in Indianapolis. ■

Dr. Munshi

Number 2

July/August 2000 • 51

1 999 was a Year to Regroup and Refocus

Dr. Lloyd
Langston (top),
past president,
and Dr. Carlton
Chambers, co-
chairman of
the Long-range
Planning
Commitee,
helped develop
goals for AMS that
will include more of
the state’s physicians.

The year 1999 was a good one for the Arkansas Medical
Society.

“I think everything went real well,” said Dr. Lloyd G. Langston,
AMS past president. “There was no major controversy in the soci-
ety, and we had a number of successes politically. I believe we im-
proved benefits for our members. We tried to open the door, to get
in better contact with our members.”

At the same time, the society continued developing relation-
ships with political candidates, legislators and Arkansas’ congres-
sional delegation while initiating talks with the Arkansas insur-
ance commissioner and managed care providers on the prompt
payment debate.

And, probably most important, the society redoubled ef-
forts to increase AMS membership.

“We want every physician in the state who works to feel
like they have a place and we are speaking for them,” Dr.
Langston said. “Unity and inclusion [are] the key. And
we’re making some real progress.”

Much of that progress, he said, has derived from the
recent hard work of the reestablished Long-range Plan-
ning Committee.

An otolaryngologist from Pine Bluff, Dr. Langston asked
a good friend, Dr. Carlton C. Chambers III, also an oto-
laryngologist, to help lead the committee, an ad hoc group
established originally to study the society and es-
tablish goals.

A primary objective has been to in-
crease AMS membership. Lagging
membership is a common problem
for many professional groups,
both doctors said. The society
wants to increase member-
ship 1 5 percent by 2003 and
has ideas how to do so, in-
cluding becoming more user
friendly, establishing a prod-
uct or service referral system
for physicians and customiz-
ing the AMS web site with
exclusive members’-only of-
ferings.

“We stimulated a great deal of
interest,” Dr. Langston said. “Carl
has been the real workhorse.”

Dr. Chambers, AMS secretary, lives
in Harrison and Little Rock and is an assis-
tant professor at the University of Arkansas for
Medical Sciences. He immersed himself in the Long-range Plan-
ning Committee duties, serving as the committee co-chairman.

“We can’t sit and be complacent,” he said. “We must reevalu-
ate who we are and where we are and where we want to go. If we

Progress Promising
on Long-Range
Planning Committee

By Judith M. Gallman

52 • The Journal

Volume 97

can come up with that, that’s our long-
range plan.”

Dr. Chambers, through the commit-
tee, polled 100 volunteer members for
opinions then had consultant Mary F.
Dillard of Little Rock, president of
Dillard & Associates Inc., facilitate two
meetings to identify issues and concerns
for a steering committee to undertake,
ultimately deciding on six goals and
strategies.

“She did a masterful job of bringing
these renegade doctors into line,” he
said.

Dr. Chambers said it’s imperative for
the society to relate each issue to what
is really going to be good for people, and
that’s the context from which the goals
were established. They are to:

• Provide leadership in developing
health care policy.

• Increase member involvement in
AMS programs and activities.

• Improve AMS’ organizational
strength.

• Strengthen the role of AMS as an
advocate for physicians and patients.

• Position the AMS as the leader in
providing education and assistance to
members.

• Produce a 15 percent increase in
membership by 2003.

The goals and strategies were ac-
cepted by the AMS House of Delegates
at the annual session, and the executive
committee was directed to abide by the
plan through the appointment of three
committees whose duties will he to pro-
mulgate the covenants, Dr. Chambers
said.

“We are now in the process of poll-
ing the membership for volunteers for the
key committees,” he said, identifying
those as relating to membership, com-
munication and governance. “These ar-
eas were determined to he the most im-
portant issues.”

The society seems to be on track to-
ward strengthening the organization. In
fact, the new AMS president, Dr. Gerald
A. Stolz Jr. of Russellville, has said he
wants to recruit more women and minor-
ity members as well as younger physicians
to make the society more inclusive.

“I will commit myself to doing the
best job possible for physicians in the
state of Arkansas and represent their in-
terests as well as I can ... but I also want
Arkansas physicians to be [involved] at
the top level, making things happen for
the society,” Dr. Stolz said.

Two of his biggest goals are address-
ing the needs of the new physicians who
are joining the society’s fold and mak-
ing sure that women and minorities are
well represented in the society’s ranks.

“I want to definitely continue the
work of the strategic planning commit-
tee because we are getting more and
more younger physicians involved in the
council,” he said. “Approximately 50
percent of the graduates of medical
schools across the United States are now
women and minorities. The profession
is changing.”

“The Medical Society has been a
white, male-dominated society; we are
making really sincere efforts to make it
as open as possible,” Dr. Chambers
agreed. “The concept is to involve ev-
erybody.” ■

Get Published...

Give something back to your
profession, write an article for

The Journal needs your thoughts and ideas.

So why not consider putting your expertise
and experience on paper?

The Arkansas Medical Society is a statewide organization that
represents all physicians, regardless of location or type of practice.
The result is a statewide network united for the common good of the
medical profession. The staff of the Arkansas Medical Society
provides members with the best information and services available.

For information about submitting an article to The Journal of the Arkansas
Medical Society , see information for Authors on the contents page of this
issue or call Judy Hicks at 501-224-8967 or 1-800-542-1058.

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Congressman Champions
Patients’ Rights

Berry Awarded Shuffield Award for Legislative Efforts

By Christy L. Smith

Rep. Marion Berry, D-Ark., believes that doctors — not
insurance companies — should make decisions regarding the
treatment of patients.

To that end, the congressman from Arkansas’ 1st district
has been a tireless champion of a Patient’s Bill of Rights to
prevent insurance providers from interfering with treatment
decisions and to hold them accountable if a patient is de-
nied care. For his efforts in this cause, Berry recently received
the highest honor the Arkansas Medical Society bestows
upon a nonphysician each year — the Shuffield Award.

“In the face of enormous pressure from the insurance in-
dustry and their use of big business to fight their battles, our
special honoree did the right thing,” said Lynn Zeno, direc-
tor of governmental affairs, at the AMS Annual Session in
May.

But Berry said it took little to convince him something
needs to be done to protect patients and physicians.

“It’s not hard to get involved in something like health
care . . . This whole issue of whether the doctor and the
patient get to decide what’s best for a patient or a clerk in an
insurance company [get’s to decide] is something I think
strikes everyone’s heart,” he said.

Berry, who grew up near DeWitt, graduated from the Uni-
versity of Arkansas for Medical Sciences College of Phar-
macy in 1965. He practiced pharmacy for three years before
taking over the family farm in Gillett.

He entered public service in 1986, serving eight years on
the Arkansas Soil and Water Conservation Commission, and
was appointed special assistant to the president for Agri-
culture Trade and Food Assistance in 1993. He also served
on the White House Domestic Policy Council.

In 1996, Berry was elected to the U.S. House of Repre-
sentatives, where he is a member of many committees and
serves as co-chairman of the House Prescription Drug Task
Force, which is working to reduce the cost of prescription
drugs for senior citizens, and the Democrat’s Health Care
Task Force.

The House passed a Patient’s Bills of Rights last Octo-
ber. The measure ensures that patients receive the treat-
ment they have been promised and have paid for, pre-
vents insurance providers from interfering with doctors’
decisions regarding treatment, ensures that patients can
go to any emergency room without calling their health
maintenance organization first, ensures that insurance

Marion Berry

providers grant access to specialists when needed and al-
lows insurance plans to be sued for making adverse medical
decisions.

A Senate version of that bill also passed last year, but
it protects the insurance companies rather than the pa-
tients and physicians, Berry said. The issue of patient
protection has now been assigned to a conference com-
mittee, a bipartisan group of representatives and sena-
tors who will try to work out the differences between the
House and Senate version of the bills.

Berry said the fight to pass a patient protection bill is
far from over. Pressure from constituents during the elec-
tion year will ensure that the measure remains a top pri-
ority for legislators during the next congressional session,
he said.

“The problem hasn’t gone away; it’s still out there. This
should not be a partisan issue . . . It’s an issue the American
people have to deal with and for that reason we should go
ahead and take care of it . . . But I can assure you that it will
come up again in the 107th Congress,” he said. ■

Number 2

July/August 2000 • 55

The Fifty Year Club honors
those physicians who have held
a license to practice medicine
for 50 years and have loyally and effectively served the com-
munity — hy skill and devotion to high ideals — upheld and
maintained the standards of the medical profession. The Ar-
kansas Medical Society hosted a breakfast for members of the
Fifty Year Club May 6, at the Embassy Suites in Little Rock
during the 124th AMS Annual Session.

Physicians who were inducted into the Fifty Year Club
this year are: Maurice K. Borklund, MD, Booneville; J . B. Cross,

MD, Little Rock; Millard C.
Edds, MD, Van Buren;
Thomas A. F ormby, MD,
Searcy; James H. French, MD, Hot Springs; G. Thomas Jansen,
MD, Little Rock; James W. Marsh, MD, Warren; Stanley R.
M cEwen, MD, Fort Smith; Walter S. M izell, MD, Little Rock;
William R. Nixon, MD, Pine Bluff; William T. Paine, MD, HeL
ena; RaymondE. Peeples, MD, Hot Springs; John E. Peters, MD,
Little Rock; Fay M. Sloan, MD, Little Rock; VestalB. Smith, MD,
Marked Tree; Chaney W. Taylor, MD, Batesville; and Thomas E.
Townsend, MD, Pine Bluff. ■

The Fifty Year Club

Arkansas Medical Society's

□

Please check if you are
an AMS member.

2nd edition

Arkansas Medical Society’s

Physician’s Legal Guide

Check enclosed in the amount of: $

Please charge my Visa or Mastercard:
Cardholder’s name:

Credit card No.:

_Exp. date: .

Cardholder’s Signature:.

Namep

Clinic:_

Address:.
City:

Telephone: ( )

Fax No.: ( )

State:

Zip:.

Call the AMS office at 501 -224-8967 or 800-542-1 058 for volume discount pricing

CREDIT CARD ORDERS
CAN BE FAXED TO:
(501) 224-6489

56 • The Journal

Volume 97

New Alliance President
Touts Active Membership

Cynthia W. We-
ber, the new president
of the Arkansas Medi-
cal Society Alliance,
has big plans for her
two-year term.

“My focus is to see
how we can change
the alliance to meet
the needs of those who are eligible to be-
come members,” she said.

“I’m going to encourage our state mem-
bership chairs to work closely with coun-
ties to get buy-in from the members,” We-
ber, 53, said, adding that her hope is the
alliance will appeal to diverse members.

Groups in general, she said, have faced
extreme difficulties keeping members in-
terested in being active. The AMS Alli-
ance, about 1,000 members strong in its
heyday, now has about 500-600 members,
a poor representation, Weber said.

Many factors are to blame for declin-
ing membership, including a younger gen-

eration of doctors whose marriages require
that both partners work. “There’s not a
lot of time for volunteer organizations.
Then, we compete with other volunteer
organizations,” she said.

“The other thing is to look at legisla-
tion, since this is a political year and the
Legislature will be in session in January.
We want to be proactive and help where
we can,” Weher said. “There are hundreds
of hills that in one way or another directly
or indirectly affect medicine.”

Weber said her goal is to convince
more members to devote time and effort
to the Alliance.

“I believe you can’t become what you
want to be by staying what you are,” We-
ber said.

Weber, who is fluent in French and
enjoys domestic and international travel,
has 1 7 years experience in business man-
agement. She has been an Alliance mem-
ber for about 20 years. Her husband, J im,
who died in 1998, was a family physician.

Weber is assistant director of educa-
tion for the department of family and com-
munity medicine at the University of Ar-
kansas for Medical Sciences. She has
worked for the department since 1996,
serving as an instructor, administrative
director for clinical services and clinic pro-
gram manager.

Previously, she was clinic administra-
tor for her husband’s practice, Weber
Medical/Surgical Clinic in Jacksonville,
for 11 years. Weber also worked at the
West Oakland Health Center in Oakland,
Calif., as assistant training coordinator and
director of staff development, and as an
education counselor. She was an assistant
to the administrator of St. Vincent Infir-
mary in Little Rock, a school teacher at
Roslyn High School in Long Island, N.Y.,
and a staff member on Gov. Winthrop
Rockefeller’s public relations office.

She is a member of the Rotary Club of
Little Rock and a member of the Congre-
gation B’Nai Israel board of directors. ■

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Report of the Council

Members of the Arkansas Medical Society Council during the Annual Meeting May 5*6.

Summary of Actions Taken:

The Council met on Saturday, May 6, 2000, and the
following business was received and transacted:

1. Approved the minutes of the Feb. 27, 2000, Comv
cil meeting and the March 22, 2000, Executive Com'
mittee meeting.

2. Received an update on the Arkansas Department of
Human Services contract with Arkansas Behavioral
Care to provide mental health services to Medic-
aid patients.

3. Discussed plans to meet with other health care or-
ganizations to research methods/programs for im-
proving patient safety.

4. Approved $25,000 of reserves he used as an initial
step to support of the initiated act process for to-
bacco settlement negotiations and review for further
participation as it progresses.

5. The Council approved requests for dues exemption
from component societies.

6. The Council approved the following committee ap-
pointments:

• Budget Committee: Brenda Powell, MD, Hot
Springs

• Journal Editorial Board: Reappoint Samuel Landrum,
MD, Fort Smith, representing general surgery; Joseph
Beck, MD, Little Rock, representing oncology; Will-
iam Ackerman, MD, Little Rock, representing anes-
thesiology

• Medical Education Foundation for Arkansas: Re
appoint Martin Eisele, MD, Hot Springs, president

• Pension Plan Committee: Reappoint John Wil-
son, MD, Little Rock

Reappoint Samuel Welch, MD, Little Rock

• Arkansas Medical Foundation: Position No. 1:
Jerry Stringfellow, MD, Texarkana

• Young Physicians Task Force: Kimberly Garner,
MD, Pine Bluff, chairman

• Medical Student Councilor: Mr. Erik Shultz, Little
Rock

7. The Membership Report, Budget Report and
MEFFA audit were presented for information.

8. Voted to accept the Arkansas Medical Society au-
dit.

9. Discussed the Arkansas State Medical Board’s pro-
posed regulation relating to Alcohol and Mind
Altering Substances in the Actively Treating Phy-
sician. The Arkansas State Medical Board is seek-
ing Arkansas Medical Society assistance in estab-
lishing policy for a physician in active status of
treating patients and the consumption of alco-
holic beverages. Gave approval for an ad hoc
committee to he formed to work on this issue.

10. Discussed an issue with Medicaid and fetal non-
stress test. The Council directed David Wroten,
AMS assistant executive vice president, to con-
tinue discussions with the Arkansas Department
of Human Services.

1 1. Discussed a recent situation where a physician
had been asked to sign a background verification
disclosure and agree to allow a detective agency
to investigate his background for a hospital staff
application. The Council directed this issue
be referred to the Executive Committee for re-
view. ■

Number 2

July/August 2000 • 59

Nee

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OF THE ARKANSAS MEDICAL SOCIETY

For Advertising Information,
Contact Stephanie Hopkins
501-372-2816 Ext. 293
Email: stephanie@abpg.com

Report of the Arkansas Medical
Society House of Delegates

1. Election of Officers:

President-elect: Joe Stallings, MD, Jonesboro
Vice President: Paul Wallick, MD, Monticello
Treasurer: Reappointed Dwight Williams, MD,
Paragould

Secretary: Reappointed Carlton Chambers III,
MD, Little Rock

Speaker of the House: Reappointed Anna
Redman, MD, Pine Bluff

Vice Speaker of the House: Reappointed Kevin
Beavers, MD, Russellville
Delegates to the AM A:

Reappointed John Burge, MD, Lake Village
Reappointed William Jones, MD, Little Rock
Alternate Delegates to the AMA:

Reappointed Lloyd Langston, MD, Pine Bluff
Hugh Jackson, MD, Fort Smith
District Councilors:

District 1: Reappointed Roger Cagle, MD,
Paragould

Jim Citty, MD, Searcy
Reappointed Parthasarathy
Vasudevan, MD, Helena
District 4: Reappointed Harold Wilson, MD,
Monticello

Reappointed Samuel Peebles, MD,
Nashville

Reappointed Robert McCrary, MD,
Hot Springs

Reappointed Thomas Eans, MD,
Little Rock

Reappointed Edward Saer, MD, Little
Rock

Reappointed John Wilson, MD, Little
Rock

D. Wayne Brooks, MD, Springdale
Thomas Langston, MD, Harrison
District 10: Reappointed Kenneth Seiter, DO,
Fort Smith

Reappointed William Galloway, MD,
Russellville

Medical Student Councilor: Mr. Erik Shultz

District 2:
District 3:

District 6:

District 7 :

District 8:

District 9:

2. Adopted the minutes of the 1999 House of Delegates
meeting.

3. Dr. Joe Beck reported on Council action taken at the
May 6, 2000, meeting. A summary will be printed in
The Journal of the Arkansas Medical Society.

4. Dr. Carlton Chambers presented a report and plan of
the Long-range Planning Committee. The plan is
printed in this issue of The Journal of the Arkansas
Medical Society. Voted to accept the plan as new business
and accept it for information. Voted to authorize the Ex-
ecutive Committee and Council to move forward with
the investigations, plans, committees and any other ac-
tion that can be taken before the next House of Del-
egates meeting.

5. Announced the members of the 2000-2001 Nominat-
ing Committee. The members are:

District 1: Leonus Shedd, MD, Paragould

District 2: J. R. Baker, MD, Batesville

District 3: Marion McDaniel, MD, Helena

District 4: David Jacks, MD, Pine Bluff

District 5: Donya Watson, MD, El Dorado

District 6: Michael Young, MD, Prescott

District 7: Timothy Webb, MD, Hot Springs

District 8: C. Reid Henry, Jr., MD, Little Rock,

secretary

District 9: Anthony Hui, MD, Fayetteville, chainnan

District 10: Timothy Waack, MD, Fort Smith

6. Selected as nominees of the Arkansas State Board of
Health and the Arkansas State Medical Board:

1st Congressional District, Arkansas State Board of
Health — Dwight Williams, MD, Paragould; Leonus
Shedd, MD, Paragould; G. Edward Bryant, MD, West
Memphis;

Member-at-Large, Arkansas State Board of Health —

Glenn Davis, MD, Little Rock; Kenneth Seiter, DO,
Fort Smith; Linda McGhee, MD, Fayetteville;
Arkansas State Medical Board — C. Eldon Tommey,
MD, El Dorado; Alan Wilson, MD, Crossett; Donald
Blagdon, MD, Camden

Number 2

July/August 2000 • 61

Long-range Planning Committee

Co-chairmen Carlton Chambers, M D, and Scott Ferguson, M D

In the summer of 1999, AMS President Dr. Lloyd Langston,
appointed a steering committee to guide the AMS through
a long-range planning process. The results of that process ap-
pear in the accompanying document. The purpose of this project
was to examine the current trends and challenges facing Arkan-
sas physicians and en-
sure that the AMS is
well-positioned to
continue the legacy of
successful representa-
tion and advocacy on
behalf of physicians
and their patients.

The steering
committee sought in-
put from a broad rep-
resentation of the
AMS membership.

An open letter went
out asking grassroots
physicians to volun-
teer their time and
input for this project.

To our surprise, more
than 100 physicians
agreed to participate.

In order to make the
best possible use of
their time, two half-
day meetings were
held with identical
agendas. This way,
each physician could
choose which day to
attend. Not enough
can be said about the
efforts of these volun-
teers. They took time
away from their prac-
tices and families to
help make the AMS
a better organization.

They deserve our
thanks and apprecia-
tion. Their names, along with the names of the steering commit-
tee members, appear in this report.

A facilitator was hired to organize the effort and keep us on
track. At the two half-day meetings, participants were asked to
identify key issues, strategies and make recommendations on
specific actions. Following these meetings the steering commit-
tee met to review the information and begin developing specific
goals and activities to achieve them.

The most profound finding to come from this process was

an obvious communication gap between the AMS and the mem-
bership. Many activities and programs were recommended that
the AMS is already doing or has done in the past. For example,
it was suggested that a web page be developed. The AMS has
actually had a web site (www.arkmed.org) for two years. It is not

so much that the AMS
does not put the informa-
tion out, it is that the in-
formation is not reaching
the intended audience.
To this end, the plan in-
cludes formation of an ad
hoc committee to inves-
tigate and recommend
improved communica-
tion strategies.

The plan contains
recommendations for
two additional commit-
tees to be formed. One
of the goals is a 15% in-
crease in membership by
2003. To accomplish
this goal, member phy-
sicians will need to play
a larger role in asking
nonmembers to join. A
committee is being rec-
ommended to accom-
plish this goal. Another
major issue is gover-
nance, and includes is-
sues such as how mem-
bers are represented in
the organizational struc-
ture, how officers are
elected and the effec-
tiveness and appropri-
ateness of our policy
making process. A com-
mittee has been recom-
mended to review our
current governance
structure and recom-
mend any needed changes.

In conclusion, the accompanying long-range plan represents
a beginning. Much work remains and ongoing efforts are needed
to ensure that our AMS remains an effective, strong advocate
for physicians and their patients. The plan represents the input
and views from a wide spectrum of dedicated physicians all of
whom have a common goal of wanting the Arkansas Medical
Society to be the voice of Arkansas physicians. We must do
whatever it takes to accomplish that goal. ■

Committee Steering Group

Omar Atiq, Pine Bluff
Joseph Beck, Little Rock
Donald Blagdon, Camden
Ms. April Davidson, Little Rock
Denise Greenwood, Little Rock
Anthony Hui, Fayetteville
Hugh Jackson, Fort Smith
William Jones, Little Rock

Lloyd Langston, Pine Bluff
Thomas Langston, Harrison
Charles Logan, Little Rock
Michael Moody, Salem
Brenda Powell, Hot Springs
Joe Stallings, Jonesboro
Gerald Stolz, Jr., Russellville
Steven Thomason, Little Rock
James R. Wharton, Springdale

Volunteers

Russell Allison, Russellville

L.J. Pat Bell, Helena

Robert Bell, Russellville

Raymond V. Biondo, North Little Rock

Thomas Braswell, England

Gilbert Buchanan, Little Rock

John Burge, Lake Village

Roger Cagle, Paragould

Raines Chaffin, Bryant

Rodney Chandler, Texarkana

Robert Choate, North Little Rock

Scott Claycomb, Warren

George Covert, Ashdown

Richard Dietzen, El Dorado

Bradley Diner, Little Rock

Thomas Eans, Little Rock

Douglas Edmondson, El Dorado

James Fasules, Little Rock

Herbert Fendley, Pine Bluff

Martin Fiser, Little Rock

Kimberly Garner, Pine Bluff

Sami Harik, Little Rock

Marion Hazzard, Paragould

Morriss Henry, Fayetteville

David Jacks, Pine Bluff

Carole Jackson, Conway

Arthur Johnson, Fort Smith

Robert Jones, Benton
Robert Kale, Fort Smith
James Kolb, Jr., Russellville
Mark Larey, Hot Springs
Larry Lawson, Paragould
Keith Lipsmeyer, Morrilton
Don Lum, Pine Bluff
John Lytle, Pine Bluff
Peter MacKercher, Mountain Home
Linda McGhee, Fayetteville
David Millstein, Mountain Home
Michael Moody, Salem
David Murphy, Russellville
Richard Nugent, Little Rock
Nick Paslidis, Little Rock
Curtis Patton, Forrest City
Chester Peeples, West Memphis
Leonus Shedd, Paragould
Gregory Slagle, Hot Springs
Scott Stern, Little Rock
Steven Strode, Little Rock
Parthasarathy Vasudevan, Helena
Paul Wallick, Monticello
Dwight Williams, Paragould
John Williams, Huntsville
Cynthia Willingham, Pine Bluff
Alan Wilson, Crossett
Morton Wilson, Fort Smith

62 • The Journal

Volume 97

Arkanas Medical Society
Long-range Plan

Mission

To serve as the voice of Arkansas physicians.

Key Values

• The highest standards of quality for health care.

• Preservation of the physician-patient relation-
ship.

• Improved access to health care for all Arkansans.

• Integrity and ethical behavior.

• Excellence in service, programs and representation.

• Respect and trust.

Goals

• Provide leadership in developing health care
policy.

• Increase member involvement in AMS programs
and activities.

• Improve the organizational strength of the AMS.

• Strengthen the role of AMS as an advocate for
physicians and patients.

• Position the AMS as the leader in providing in
formation, education and assistance to members.

• Produce a 15 percent increase in membership by

2003.

A. Provide Leadership in Developing
Health Care Policy

Strategies

• Continue to strengthen AMS legislative and
regulatory advocacy efforts.

• Use Internet technology to enhance communi-
cations with physicians regarding legislative and
regulatory issues.

• Teach patients and physicians how to be pro-
active advocates for improving health care poli-
cies.

Actions

1. Sponsor meetings between the AMS leadership
and the leadership of other physician and health
care organizations to discuss current and emerg-
ing health care issues.

2. Seek ways to increase funding for AMS govern-
mental affairs activities.

3. Sponsor a program for legislators to be “doctor
for a day” through local physician offices.

4. Conduct regular meetings between AMS physi-
cian leadership and elected legislative leaders.

5. Sponsor periodic meetings between physicians and
representatives of the various agencies/commis-
sions to address physician and patient concerns.

6. Develop tools to inform physicians about the roles
and responsibilities of the various agencies/com-
missions, with an emphasis on the role of AMS
and physicians in the policy-making process.

7. Survey the leadership of medical specialty societ-
ies to help identify legislative issues that should be
addressed by the AMS.

8. Utilize the AMS web site to improve communica-
tion with members during legislative sessions, in-
cluding the formation of a bulletin board.

9. Provide information on the AMS web site for mem-
bers to use in communicating with their patients
about health care issues.

1 0. Provide material for physicians to use in their wait-
ing rooms to educate patients about how to com-
municate with their state and federal legislators
and agencies about health care issues.

B. Increase Member Involvement in AMS
Programs and Activities

Strategy

• Recognize the changing nature of physicians’ prac-
tices and physician demographics and develop pro-
grams and communication methods to meet their
specific needs.

Actions

1. Conduct informal meetings and ongoing discus-
sions with new physicians, women physicians, for-
eign-born physicians and employed physicians to
identify programs, services and communication
methods that better meet their needs.

2. Recruit representatives of the Society to make per-
sonal visits to physicians and physician groups to
provide information and encourage involvement
in the AMS.

3. Form an ad-hoc committee to investigate and rec-
ommend improved communication strategies, in-
cluding a review of AMS publications and use of
Internet-based technology.

Continued

Number 2

July/August 2000 • 63

C. Improve the Organizational Strength of
the AMS

Strategies

• Provide broader and more effective participation
in the governance of the AMS with more infor-
mal avenues of participation.

• Establish an ongoing annual planning process.

Actions

1. Charge the AMS Executive Committee with the
responsibility to annually review the long-range
plan and recommend appropriate action to address
emerging and evolving trends.

2. Establish a task force to review the strengths and
weaknesses of the AMS organizational structure,
and if needed, recommend changes to ensure broad
representation, meaningful participation, continu-
ity of leadership and the efficient conduct of busi-
ness. This review should include, at a minimum, a
critical look at each of the following:

a. House of Delegates

b. Council

c. Executive Committee

d. Nomination and election process

e. Representation of membership and membership
groups

D. Strengthen the Role of AMS as an
Advocate for Physicians and Patients

Strategies

• Provide information and education to patients so
they can become advocates for improved health
care policies and preservation of the patient-phy-
sician relationship.

• Provide accurate and timely information on health
care issues to the public.

• Recognize and promote contributions that physi-
cians make to improve the quality of life and society.

Actions

1. Develop brochures, fact sheets and/or newsletters
that physicians can utilize in their waiting rooms
to help educate patients about health care issues.

2. Direct the ad hoc Committee on Communica-
tion to explore the development of a public rela-
tions plan to promote the AMS and its members’
contributions to health care in Arkansas.

3 . Develop public information/education programs in
collaboration with other health-related groups such
as the Arkansas Foundation for Medical Care and
Arkansas Department of Health.

4. Submit regular articles and editorials to the media
regarding current health care issues.

5. Establish an award to recognize physicians whose
activities and lives epitomize the spirit and humani-
tarian nature of medicine. The award should be

modeled after the American Medical Association’s
Pride in the Profession program.

E. Position the AMS as the Leader in
Providing Information, Education and
Assistance to Members

Strategies

• Improve member awareness of AMS activities and
programs.

• Utilize new technologies to provide education and
information.

• Develop new programs to meet the professional
and business needs of members.

Actions

1. Formally request that the Board of Directors of
the AMS’ educational foundation, MEFFA,
broaden its mission to include funding for AMS
sponsored educational programs directed at prac-
ticing physicians, medical students and residents.

2. Develop a referral database for assistance and pro-
fessional advice on issues such as coding, fraud and
abuse, practice evaluation and contract review.

3. Develop a peer-to-peer assistance program to pro-
vide a referral source of physicians who are will-
ing to share their experiences with computer sys-
tems, software, telephone systems and other topics.

4. Investigate the development of a Member’s Only
Section of the AMS web site to provide:

a. easy access to Internet-based and traditional con-
tinuing medical education resources;

b. bulletin board programs for discussion and ex-
change of ideas;

c. legislative updates and alerts;

d. online registration and payment for AMS spon-
sored programs and publications;

e. searchable database of AMS membership; and

f. information on AMS services and benefits

F. Produce a 1 5 % Increase in Membership
by 2003

Strategies

• Survey non-members to determine strategies for
meeting their needs and recruiting them to the AMS.

• Target senior residents and medical students.

• Develop a grassroots physician-to-physician mem-
bership development plan.

• Increase involvement of new members in the So-
ciety.

Action

1. Establish a Committee on Membership to develop
an effective physician-to-physician contact system for
recruiting and retaining members and to assist the
AMS staff in identifying effective strategies to strengthen
the bond between physicians and the AMS. ■

64 • The Journal

Volume 97

A Special Thank You

to the following companies
for their contributions to the 124th AMS Annual Session, May 5 -6, 2000, at the
Embassy Suites in Little Rock. This meeting would not have been possible without the
financial support of these organizations .

Gold Star Contributors

AMS Benefits Inc.

American Investors Life Insurance Co.

Arkansas Blue Cross and Blue Shield
Arkansas Foundation for Medical Care
Arkansas Managed Care Organization (AMCO)

Aventis Pharmaceuticals
Bank of Mulberry
Bank of the Ozarks Trust Services
Bayer Pharmaceuticals
Medical Assurance
Metropolitan National Bank
Regions Bank

State Volunteer Mutual Insurance Co.

2000 AMS Exhibitors

AMS Benefits Inc.

Arkansas Army National Guard Medical Recruiting Team
Arkansas Blue Cross and Blue Shield
Arkansas Health Care Access Foundation
Arkansas Heart Hospital
Arkansas Managed Care Organization (AMCO)

Arkansas Medicaid Deferred Compensation Program

Arkansas Medical Group Management Association

Arkansas Medical Society

Becker Inc. — Prodenco

Commodore Medical Services

Diagnostic Imaging

Disability Determination for Social Security
Diversified Investment Advisors
Doctors Insurance Reciprocal

Employers Healthcare Resources
G.D. SEARLE

Horton’s Orthotic Lab Inc.

Hutchinson/Ifrah Financial Services Inc.

Jefferson Regional Medical Center

Key Pharmaceuticals

KOS Pharmaceuticals

Lee Pharmacy

Martek USA Inc.

Medicaid Managed Care Services
Metropolitan National Bank
Pathology Practice Management & Tri-Path Corp.
Personal Communication Systems (PCS)

Pfizer — Labs, Pratt and Steere Divisions

Professionals Advocate (ProAd) Insurance Co.

RehabCare Group

Research Solutions

Roche Laboratories

Schering Corp.

Schering Oncology/Biotech
SmithKline beecham Pharmaceuticals
Snell Prosthetic & Orthotic laboratory
Sprint PCS
St. Paul Companies

State Volunteer Mutual Insurance Co.

Tap Pharmaceuticals
U.S. Air Force

U.S. army Health Care Recruiting
web md

World Wide Travel

Number 2

July/August 2000 • 65

PEOPLE+EVENTS

Radiology Association Honors Dr. Ferguson
for Distinguished Public Service

Dr. Scott Ferguson, a West Memphis radi-
ologist, recently received the Distinguished Ser-
vice Award by the American Chapter of the Col-
lege of Radiology.

Dr. Ferguson, a former state representative,
was honored with the award in recognition for
outstanding public service in health care. A radi-
ologist at Outpatient Radiology in West Memphis
and Baptist Memorial Hospital in Osceola, he
served on the state legislature’s Public Health, La-
bor and Welfare Committee and the City and
County Affairs Committee.

“I was really very honored and very pleased,”
Dr. Ferguson said about receiving the award.

He worked in the legislature and the Arkan-
sas Medical Society to advance patients’ rights
legislation and traveled to Washington, D.C., to
lobby senators and congressmen for passage of the
Patients’ Bill of Rights.

Dr. Scott Ferguson, left, receives the Distinguished Service Award from
the Arkansas chapter of the American College of Radiology from Dr.
Terry Olson, president of the radiology group.

HONORED

Dr. Eans Attains MRO
Certification,
Publishes Article

Dr. Thomas Eans of

Southwest Family Clinic in
Little Rock recently became
certified as a medical review
officer.

Dr. Eans, a general prac-
tice physician, earned the
credentials from the Ameri-
can Association of Medical
Review Officers Inc., a non-
profit medical society created
in 1991 to establish national
standards and certification of
medical practitioners and
other professionals in the
field of drug and alcohol test-

ing. Certification is intended
to ensure quality services and
ethical conduct by profession-
als involved in drug and al-
cohol testing.

The MRO is an integral
part of federally mandated
drug testing programs and bal-
ances the protected rights of
the tested individual and the
concerns for health and safety
in the workplace.

Dr. Eans also recently
published an article, “New
HCFA Drug-Prescribing Cri-
teria for Nursing Homes and
Suggested Alternate Prescrib-
ing to Avoid Care Deficien-
cies” in the February 2000 is-
sue of the Annals of Long-Term
Care: Clinical Care and Aging.

AMA Names PRA
Recipients

Each month the Ameri-
can Medical Association pre-
sents the Physician’s Recogni-
tion Award to those who have
completed acceptable pro-
grams of continuing education.

AMA recipients for March
include Drs. Sorin Jos Brull,
Hugh F. Burnette and Carlton
L. Chambers, all of Little Rock,
and Dr. Wilbur M. Giles of
Newport.

Ceremony Marks
Dedication of
Schoettle Center

The Dr. Glenn P.
Schoettle Medical Education
Center at Crittenden Me-

morial Hospital was dedi-
cated this year with Dr.
Schoettle’s family on hand
for the ceremony that
marked the opening of the
new building.

The 7,500-square-foot
building features a 76-seat
auditorium, two meeting
rooms and a physicians’
study room. The center is
equipped with state-of-the-
art technology facilities for
meetings and seminars, in-
cluding satellite uplinks for
medical conferencing.

The Glenn Schoettle
family donated the center to
honor the former heralder
and teacher of health care
professionals.

66 • The Journal

Volume 97

OBITUARIES

Paul J. Cornell, MD

Dr. Paul J. Cornell, 64, of Little
Rock and Boundurant, Wyo., a retired
practitioner of obstetrics and gynecol-
ogy, died May 17, 2000.

Dr. Cornell attended Tulane Uni-
versity and Louisiana State University
Medical School and completed his intern-
ship in obstetrics and gynecology in the
U.S. Army Medical Corps. He served
as commanding officer of two Army sur-
gery evacuation hospitals in the TET Of-
fensive in the Vietnam War.

Dr. Cornell was active in the Arkan-
sas Medical Society as a councilor and
served as the Pulaski County Medical
Society president in 1979. He is sur-
vived by his wife, JoAnn Louise
Cornell; his mother, Anne A. Cornell
of Little Rock; a brother; three children;
and eight grandchildren.

Donald J. McMinimy, MD

Dr. Donald J. McMinimy, 80,

FACP, of Fort Smith died May 15, 2000.
He was an internal medicine physician
with Holt-Krock Clinic for 30 years and
a Navy veteran. He also was a member
of First Baptist Church, the Sebastian
County Medical Society, American
Medical Association and the American
College of Chest Physicians. He was a
fellow in the American College of Phy-
sicians.

He is survived by his wife of 58 years,
Nell, a daughter, three grandchildren and
one great-granddaughter.

Frank M. Burton, MD

Dr. Frank M. Burton, 92, a gen-
eral surgeon in Hot Springs, died May 5,
2000, in St. Joseph’s Regional Health
Center from heart and kidney failure.

Dr. Burton practiced medicine for 40-
plus years with Dr. W. Martin Eisele at
the Burton-Eisele Clinic on Whittington
Avenue, established in 1955. Over his
career, Dr. Burton served as chief of staff
at St. Joseph’s Hospital and secretary of
the Fevi Memorial Hospital Physicians’
Staff. A fellow in the American College
of Surgeons, he also was a member of the
Southwest Surgical Congress, the Inter-
national College of Surgeons and the

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American Medical Association.

A 1934 graduate of the University
of Arkansas School of Medicine in Little
Rock, he spent his internship in Shreve-
port, La., at Charity Hospital.

Dr. Burton also was a long-time
president and secretary of the Arkansas
State Medical Board, and he was a U.S.
Army Reserves and U.S. Army Medi-
cal Corps veteran, serving as chief of
staff of the U.S. Army at Omaha
Beach.

Dr. Burton, president of the Cadu-
ceus Club of the Arkansas Medical So-
ciety, was active in educational, civic,
medical military and church aspects of
his community, and he was a descen-
dant of the Belding family, the origi-
nal permanent settlers who arrived in
Hot Springs from Amherst, Mass., in
1828.

Dr. Burton was married to his wife,
LaRue Roman Williams Burton, for 59
years. He is survived by a son, daugh-
ter, grandson, a sister and many nieces
and nephews.

Clark M. Baker, MD

Dr. Clark M. Baker of Paragould
died May 29 at his home. Dr. Baker had
practiced medicine in Paragould 41
years, retiring in 1989. Born in
Maynard, he received his bachelor’s
degree from Arkansas State University
and was later Bono School District su-
perintendent until attending medical
school in 1942, graduating in 1945. He
interned at St. Vincent Infirmary in
Little Rock, then attended the School
of Aviation Medicine at Randolph
Field, Texas, until 1947. Dr. Clark
served with the U.S. Army at the 49th
General Hospital in Tokyo in 1948,
and he was base surgeon at the 3rd
Group, Yokia Air Force Base. Dr. Clark
was a member of the original medical
staff of Community Methodist Hospi-
tal (now Arkansas Methodist Hospi-
tal) in 1949. He served as chief of staff
at AMH in Paragould in 1955, 1960
and 1970. He also was a member of the
Greene-Clay County Medical Society,
the Arkansas Medical Society and the
American Medical Association, and he
also was an avid ham radio operator
with the call numbers WA5KQS. ■

ARKANSAS MEDICAL SOCIETY OFFICERS 2000-2001

Executive Committee

Chairman of the Council: Joseph Beck,
Little Rock

President: Gerald Stolz, Russellville
President-elect: Joe Stallings, Jonesboro
Secretary: Carlton Chambers, Little Rock
Treasurer: Dwight Williams, Paragould
Immediate Past President: Lloyd Langston,
Pine Bluff

Other Officers

Vice President: Paul Wallick, Monticello
Speaker of the House: Anna Redman,
Pine Bluff

Vice Speaker: Kevin Beavers, Russellville

Medical Student Section Officers

President: Dwight Johnson, Little Rock

Vice President: Charles Mashek, Little
Rock

Secretary/Treasurer: Matthew Kincade,
Maumelle

AMS Delegate: Blake Geren, Little Rock
AMS Alternate Delegate: Heather
Diemer, Little Rock

AMA Delegates

John Burge, Lake Village
William Jones, Little Rock
Larry Lawson, Paragould

AMA Alternate Delegates

Lloyd Langston, Pine Bluff
Charles Logan, Little Rock
Hugh Jackson, Fort Smith
Michael Moody, Salem

COUNCILORS 2000-2001

Medical Student Councilor

Erik Shultz, Little Rock

District 1:

Roger Cagle, Paragould
Scott Ferguson, West Memphis
Counties: Clay, Craighead, Crittenden,
Greene, Lawrence, Poinsett, Randolph

District 2:

Lloyd Bess, Batesville
J im Citty, Searcy

Counties: Cleburne, Conway, Faulkner,
Fulton, Independence, Izard, Jackson,
Sharp, Stone, White

District 3:

Dennis Yelvington, Stuttgart
P. Vasudevan, Helena
Counties: Arkansas, Cross, Lee, Lonoke,
Monroe, Phillips, Prairie, St. Francis,
Woodruff

District 4:

John O. Lytle, Pine Bluff
Harold Wilson, Monticello
Counties: Ashley, Chicot, Desha, Drew,
Jefferson, Lincoln

District 5:

William Dedman, Camden
Counties: Bradley, Calhoun, Cleveland,
Columbia, Dallas, Ouachita, Union

District 6:

Michael Young, Prescott
Samuel Peebles, Nashville

Counties: Hempstead, Howard,
Lafayette, Little River, Miller, Nevada,
Pike, Polk, Sevier

District 7 :

Brenda Powell, Hot Springs
Robert McCrary, Hot Springs
Counties: Clark, Garland, Grant, Hot
Spring, Montgomery, Saline

District 8:

Joseph Beck, Little Rock
Thomas Eans, Little Rock

C. Reid Henry, Little Rock
William Jones, Little Rock
John L. Wilson, Little Rock
J. Mayne Parker, Little Rock
Anthony Johnson, Little Rock
Samuel Welch, Little Rock
County: Pulaski

District 9:

Anthony Hui, Fayetteville
Thomas Langston, Harrison
Jan Turley, Rogers

D. Wayne Brooks, Springdale
Counties: Baxter, Benton, Boone,
Carroll, Madison, Marion, Newton,
Searcy, Van Buren, Washington

District 10:

Robert Sanders, Fort Smith
William Galloway, Russellville
Mike Berumen, Fort Smith
Kenneth Seiter, Fort Smith
Counties: Crawford, Franklin, Johnson,
Logan, Perry, Pope, Scott, Sebastian, Yell ■

68 • The Journal

Volume 97

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HealthLink of Arkansas 48

Hoffman-Henry Insurance Corp 49

Hutchinson/lfrah Financial Services Inc 44

Little Rock Medical Association 50

Maggio Law Firm 54

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Metropolitan National Bank 67

PhyAmerica Physician Services Inc 53

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Smith Capital Management 67

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Southwest Capital Management Inc 49

State Volunteer Mutual Insurance Co 40

University of Arkansas for Medical Sciences 70

Special Publications Publisher

Editorial Art Director

Brigette Williams

Irene Forbes

Special Publications

Advertising Art Director

Editor- in -Chief

Matt Stewart

Natalie Gardiner

Advertising Coordinator

Managing Editor

Kristen Ebbing

Judith M. Gallman

Marketing Assistant

Assistant Editor

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70 • The Journal

Volume 97

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important things that human beings can do for
one another. It means I'll do only my best for you.
I'll fight for your rights. I'll be there for you.

At Snell Laboratory we make that type of commitment to
each of our patients. We dedicate ourselves to making
them as comfortable and as mobile as possible. We give
them back as much of their former life as we can.

A Match Made In Heaven.

So regardless of what responsibilities your

patients agree to in life, from going out to play to
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Founding Members of PrimeCare O&P Network - serving the southern United States.

Volume 97 Number 3
September 2000

Journal

OF THE ARKANSAS MEDICAL SOCIETY

Winner of the ASAE Excellence in Communications Award

CONTENTS

FEATURES

82 Vice President Pushes for Patients’ Bill of Rights

Vice President A l Gore recently paid a visit to Little Rock
touting passage of the Patients’ Bill of Rights. Little Rock
breast surgeon Dr. Denise Greenwood told of her own
horrors with insurance companies and introduced Gore.

83 It’s Not a Man’s World Anymore

September is Women in Medicine month, and The Journal
profiles six of the state’s outstanding women physicians.
Although women doctors faced hurdles in the beginning, they
are now major contributors to medicine. Almost 40% of
current medical students are women.

84 Dr. Susan Ward-Jones, rural health

86 Dr. Sandra Marchese Johnson, dermatology research

88 Dr. Sidney Hayes, state Medicare medical director

90 Dr. Sue Chamber, pediatrics

92 Dr. Brenda Powell, obstetrics/gynecology

94 Dr. Anna Redman, family practice

DEPARTMENTS

79 Commentary

Lee Abel, MD

81 What We’ve Done
For You Lately
96 Loss Prevention

98 Cardiology Report

101 People + Events

102 Index to Advertisers

Physicians must maintain a human
touch despite patient’s expectations
of perfection .

— page 19

Vice President A l Gore spoke about
the Patients’ Bill of Rights during a
recent campaign stop.

— page 82

Number 3

September 2000 • 77

i:i)ic/\[i) I ioni/o n s

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COMMUNICATIONS COORDINATOR

Judy Hicks

EXECUTIVE VICE PRESIDENT

Kenneth LaMastus, CAE

ASSISTANT EXECUTIVE VICE PRESIDENT

David Wroten

EDITORIAL BOARD

Jerry Byrum, MD
Joseph M. Beck, II, MD
Lee Abel, MD
Samuel Landrum, MD
Jerry Kendall, MD
William Ackerman, MD

Pediatrics
Oncology
Internal Medicine
Surgery
Family Practice
Anesthesiology

EDITOR EMERITUS

Alfred Kahn Jr., MD

ARKANSAS MEDICAL SOCIETY
2000-2001 OFFICERS

Gerald A. Stolz, Jr., MD, Russellville
President

Joe Stallings, MD, Jonesboro
President-elect

Paul A. Wallick, MD, Monticello
Vice President

Lloyd G. Langston, MD, Pine Bluff
Immediate Past President

Carlton L. Chambers, III, MD, Harrison/Little Rock
Secretary

Dwight M. Williams, MD, Paragould
Treasurer

Anna Redman, MD, Pine Bluff
Speaker, House of Delegates

Kevin Beavers, MD, Russellville
Vice Speaker, House of Delegates

Joseph M. Beck, 11, MD, Little Rock
Chairman of the Council

Established 1890. Owned and edited by the Ar-
kansas Medical Society and published under the di-
rection of the Council.

Advertising Information: Contact Stephanie
Hopkins, P.O. Box 3686, Little Rock, AR 72203;
(501) 372-2816.

Postmaster: Send address changes to: The Journal
of the Arkansas Medical Society, P. O. Box 55088,
Little Rock, Arkansas 72215-5088.

Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.

The Journal of the Arkansas Medical Society
( ISSN 0004- 1 858) is published monthly by the Arkan-
sas Medical Society, #10 Corporate Hill Drive, Suite
300, Little Rock, Arkansas 72205 . Printed by The Ovid
Bell Press, Inc., Fulton, Missouri 65251. Periodicals
postage is paid at Little Rock, Arkansas, and at addi-
tional mailing offices.

Articles and advertisements published in The Jour-
nal are for the interest of its readers and do not
represent the official position or endorsement of The
Jountal or the Arkansas Medical Society. The Journal
reserves the right to make the final decision on all
content and advertisements.

78 • The Journal

Volume 97

COMMENTARY

Brilliant Disguise

By Lee Abel, MD

Bruce Springsteen was coming to town. In recognition of
this, we put on the Springsteen greatest hits CD for our
dinner cleanup music. It’s a sign of my age I guess, hut I
think the chief function of rock ’n’ roll music is to make dinner
cleanup more enjoyable. I can do some really cool moves as I
sponge off the kitchen table, although this seems to make my
two teen-agers gag. I often don’t pay much attention to the lyrics,
but on this particular night I did and was intrigued by Springsteen’s
song “Brilliant Disguise.” It’s a great tune; maybe you know the
refrain: So tell me who I see/ When I look in your eyes/ Is that
you baby/Or just a brilliant disguise?

As physicians we have opportunities to see
that the external, the superficial appearance —
the sometimes brilliant disguise — is just one
aspect of a person and not the whole picture. The
song made me think of a patient who seems to be
the very epitome of success hut in the exam room
another side emerged. He was worried and
unhappy and generally dissatisfied with his life,
despite the external appearance of happiness,
affluence and success. I also thought of a woman
I have seen whose external appearance was
immaculate (maybe even perfect) hut in the exam
room the surface image gave way to an inner
picture of anxiety, turmoil and despair.

This is not unusual. We are social animals,
and most of us want acceptance and approval.

We think about the image we present to others
and want other people to think we “have it all
together." Advertisers use this need constantly.

We are exhorted to buy products because as one
ad used to say, “It says so much about you.”

We also receive pressure from other people
to be a certain way because of their needs. I once
saw a patient who was a pastor in a small town
who came to see me because he was fatigued. He
was a very good person, but he felt his
congregation wanted him to be perfect. He tried
to be always kind, patient, loving and unselfish,
hut he couldn’t quite manage it. The pressure to be perfect became
burdensome, and I think this was the cause of his exhaustion.

Doctors also have a lot of pressure to meet certain
expectations. Patients want to see us as wise and compassionate
— indeed they may hope we are “called to” medicine as people
are “called to” the ministry. Patients may invite us to wear the
mask that fulfills their fantasy of the perfect doctor, and sometimes
their invitation can he quite persuasive. There is a part of us that
would like to be the perfect doctor, a part that would like to meet
our patients’ expectations even if those expectations are
unrealistic. And maybe we feel guilty when we don’t.

In medical school we learned to play the role of a doctor
before we were doctors. We were taught what image to project.
The lessons were implicit and explicit. On my third year surgery
rotation the attending wanted us to answer all his questions with
confidence and an air of certainty. He told us he would rather us
give the wrong answer in a confident demeanor than to give the

correct answer in a timid and unsure manner. I found this
difficult, and I found the attending intimidating, hut 1 think I
now have some insight into what he was doing. I think he
believed that we would all eventually get the right answers and
score well on written tests; what he felt we needed to learn and
couldn’t learn from books was an attitude of confidence and
authority. I think he believed that this attitude was essential to
the healing work of a physician. Being able to convince the
patient they are going to get better is a very valuable skill.

Of course, the authoritarian and paternalistic mask that
my surgical attending encouraged has its
limitations. In that role it could be hard for a
doctor to say, “I don’t know,” and shameful to
say, “I’m not sure.” Doctors could be very
certain and very wrong. “Your father has two
months to live.” “This patient will never walk
again.” This model could sometimes give rise
to a harsh judgmental attitude. In addition,
patients were often treated as passive bystanders
rather than active participants in their care.
They were given reassurance but little
information.

This style of practice is not as common now
as it was in the past. Nowadays there is a
tendency to go to the other extreme. The legal
system is so threatening and punitive that it
can activate our self preservation instincts. It
encourages a defensive way of relating to
patients that can make giving reassurance feel
legally risky. It can feel safer to wear a legalistic
mask and emphasize the uncertainties or just
keep ordering more tests. This is frustrating
for patients and may he one of the reasons for
the surging popularity of alternative medicine
whose practitioners often make dramatic
claims for the safety and benefits of their
treatments.

Perhaps the most subtle and easy to take
on brilliant disguise is the one which is
encouraged by the very structure of the doctor-patient
relationship. We see people at their most vulnerable and they
see us in our most competent mode. We see them when they are
troubled, hurting and confused. They see us when we are in our
element: our offices, our hospital, our space. We are the expert
and they are the needy. It is easy to begin to believe that perhaps
we are different creatures; that we are some superior being and
they some inferior being. It is attractive to forget (or deny) our
own shortcomings, areas of incompetence and hurts. But it is
these parts of us that make us human, and in the long run they
can he sources of wisdom, humility and connection. Keeping in
mind the wholeness of our patients (though we may only see a
part) and owning our own humanity can help keep the doctor-
patient relationship healthy.

The next song after “Brilliant Disguise” on the Springsteen
CD is “Human Touch,” and that’s certainly an essential part of
being a physician. ■

Patients may invite
us to wear the mask

that fulfills their
fantasy of the
perfect doctor, and
sometimes their
invitation can be
quite persuasive.

Number 3

September 2000 • 79

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80 • The Journal

Volume 97

WHAT WE’VE DONE FOR YOU LATELY

The AMS Health
Benefit Plan — a Eulogy

By David Wroten

While our title for this month’s article may sound ominous, remember that
the word “eulogy” is synonymous with “praise.” The difference, of course,
is that praise is usually given to someone still with us, while a eulogy is
reserved for someone who has died. However, in this case the eulogy is not for a
person.

For the past eight years, physicians and their employees have reaped the benefits
and cost savings from an AMS sponsored health insurance program known as the
AMS Health Benefit Plan. The continuation of this program is in doubt due in part
to the take-over of American Investors Life Insurance Co. by the Arkansas Insurance
Department.

In 1992-1993, the AMS created the plan as a self-funded, group health program.
There were good reasons. Many carriers had stopped writing small employers. The
vast majority of clinics fall into this “small employer” category with two-nine
employees. Some carriers were actually avoiding medical clinics on the assumption
that physicians and their employees overuse services. Health maintenance
organizations were beginning to market exclusive provider health plans, and clinics
were looking for alternatives. In 1995, the AMS plan became fully insured through
American Investors, and hy the year 2000 had grown to include 90 clinics, more
than 2,000 employees and family members.

The plan was designed to succeed. While similar to a “standard” insurance plan,
it differed in several ways. For example, the benefits were customized for physician
clinics, small clinics were not automatically charged higher premiums and claims
experience for the AMS plan was reviewed separately from the carrier’s other business.
These factors had a major impact on the premium savings enjoyed by the plan
participants. However, the single most important benefit was not cost but service.

The AMS created a wholly-owned subsidiary, AMS Benefits, to market and
service the insurance program. Not only did AMS Benefits market the plan, it
conducted the enrollments, responded to most customer service calls, did the billing
and served as the repository for all claims. Except in cases involving legal
determinations, participants never had to call the carrier. In today’s high-tech world
of automated phone systems and anonymous customer support staff, our participants
enjoyed the benefit of only having to call one person and always knowing that person
by first name.

The take-over of American Investors was unfortunate yet unavoidable given the
multitude of problems that have plagued the carrier for the last couple of years. In
anticipation of such an event, AMS Benefits searched to no avail for a year to find a
carrier that could duplicate the success of the AMS Health Benefit Plan.

With the possibility that American Investors will he liquidated, AMS Benefits
has obtained agreements with several carriers to separately quote each clinic. Most
will see their premiums go up, especially small clinics with two-nine employees. Some
of the large clinics may actually have difficulty obtaining other coverage. Certainly,
the specialized benefit design and cost savings will be gone.

The passing of the AMS Health Benefit Plan is not unlike the death of an old
friend. We often fail to appreciate their true value until they are gone. However, by
continuing to use AMS Benefits as their “agent,” clinics will still have the support
and assistance they have come to expect, and after the turmoil has passed, we can
hopefully begin looking for innovative ways to develop a new association plan. ■

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Number 3

September 2000 • 81

Vice President Pushes for
Patients' Bill of Rights

Local Physicians Share Stage with Al Gore at UAMS Campaign Stop

By Natalie Gardner

Presidential candidate A l Gore and Little Rock breast surgeon Dr. Denise Greenwood
speak out for patients’ rights.

r. Denise Greenwood, a breast
surgeon in Little Rock, recently
joined Vice President Al Gore on
a University of Arkansas for Medical
Sciences’ stage to address the need for
a Patients’ Bill of Rights. A bipartisan
version of the bill passed the House of
Representatives and is one vote away
from achieving majority in the Senate.

Dr. Greenwood told a personal
story of a patient denied care by a
health maintenance organization and
voiced her concern for medical
decisions made by insurance
accountants.

“I was too naive when I left my
training here at UAMS,” Dr.
Greenwood told an audience of about
600 July 1 1 . “1 left the safety of that and
am now being dictated how to take care
of patients by insurance companies.

“We have got to get back to letting
the patient and the physician decide
what needs to happen. We need to be
able to individualize medicine based on
appropriate uses.”

With a stage full of physicians
sitting behind him, Gore told the
audience if elected president he would
fight the “Do-Nothing Congress.”

“It seems to me to be a no-brainer,”

Gore said. “After all the training doctors
and nurses have acquired,
then to have their care-
fully prepared decisions
casually overturned by an
accountant, it’s outrageous.

“These financial
people don’t have the
right to play God.”

Gore said the federal
government shouldn’t
put doctors in a position
of having to deceive
insurance companies to

get care for their patients.

“We shouldn’t have a situation that
requires national media coverage on a
case-by-case basis [to get the right
decision made],” he said.

Gore blames the bill not passing
because of special interest money
influencing leaders of Congress.

“It is time for Congress to serve the
people, not the powerful,” Gore said.

Gore ended his speech with a Q&lA
session featuring several insurance
company horror stories told by
physicians in the audience. ■

Gore is in favor of the bipartisan Norwood-
Dingell bill that includes:

• Protections for all Americans in health plans;

• Protections from financial sanctions for patients
accessing emergency room care;

• Access to health care specialists and clinical trials;

• Access to a fair and timely appeals process to
address health plan grievances; and

• Enforcement mechanisms that ensure recourse
for patients who have been harmed as a result
of a health plan’s decision.

82 • The Journal

Volume 97

Photo: Kirk Jordan

BY CHRISTY L. SMITH

No Longer

A Man's
World

Women Continue to
Move Medicine Forward

Women have always played an
integral role in the medical
profession. Albeit, for much of
history, women served as midwives, nurses
and holistic healers; the role of physician was
closed to women.

But in the last three decades, the
profession has experienced a surge of women
physicians. According to the American
Medical Association, the number of women
practicing medicine in this country has increased
nearly sevenfold — from 25,401 in 1970 to
177,030 in 1998.

September celebrates those women and their
growing number of achievements in the medical
field. Indeed much has changed since Elizabeth
Blackwell applied to medical school in 1874 and
was accepted because the faculty and student body
at Geneva College (now Hobart and William Smiths
College) in New York thought her application was a
joke.

The number of women applying to medical
schools across the country has increased
dramatically from 2,289 in 1970 to 17,787 in 1998,
according to the AMA. And that trend has carried
itself out in Arkansas, as well.

“When I was a freshman in medical school in
1972, there were very few women in the classes. It
has certainly increased,” said Dr. Richard Wheeler,
executive associate dean for student and academic
affairs at University of Arkansas for Medical
Sciences.

Dr. Wheeler, who assumed his administrative role
at UAMS 1 1 years ago, said the percentage of
women in medical school classes has “remained
stable” at about 40% during the last few years.

According to Tom South, director of admissions
at UAMS, the number of women entering medical
school at UAMS in 1970 was 17, or 14% of the
class of 124 students. In fall 2000, that number will
be 55, or 37% of the class of 150, he said.

And women physicians are now venturing into
specialties that have long been dominated by men,
Dr. Wheeler said.

“The biggest change I’ve seen is that there has
been a dramatic shift in the number of women going
into OB/GYN and the number of women in the

general public who want to go to a woman
gynecologist,” he said.

According to the AMA, 12,885 women physicians
specialized in obstetrics and gynecology in 1998.

Only 1,337 women practiced OB/GYN in 1970.

Other specialties have seen similar increases,
according to the AMA. For instance, women
specializing in internal medicine jumped from 2,383
in 1970 to 33,307 in 1998; and women practicing
pediatrics rose from 3,816 in 1970 to 26,752 in 1998.

Changing attitudes about women’s abilities have
probably attributed to the trend, Dr. Wheeler said.

“If I had to guess, I would say that it is the result of
a general attitude that women have as much right in
the profession and do as well in the profession as
men,” he said.

That’s a far cry from the attitude that greeted
Blackwell when she graduated — with honors — from
medical school in 1 849. The first woman to receive a
medical degree in the United States moved to England
to study in hospitals that were more accepting of her. In
1851, Blackwell moved back to New York to begin a
private practice. Because male physicians refused to
work with a female associate, Blackwell opened her
own hospital for indigent women and children in a
New York City slum. That hospital still operates today
as New York Infirmary-Strang Clinic.

When a female friend suggested to Blackwell later
in her life that women should continue to occupy a
secondary role in the medical profession, Blackwell
replied that she did not strive to give women a primary
or secondary role in the field, just the freedom “to take
their true place, wherever it may be." ■

Number 3

September 2000 • 83

Dr Susan Ward-lones

Internal Medicine/
Rural Health

BY CHRISTY L. SMITH

At the age of 8, Dr. Susan Ward-Jones
already was making hospital rounds.

The 35-year-old medical director of
East Arkansas Family Health Center
in West Memphis remembers being dropped
off after school at Helena Hospital, where her
mother worked as a registered nurse. She
passed the time by accompanying doctors on
their rounds.

“I have always wanted to be doctor. My
mother would always say, ‘If you can be a
nurse, then you can certainly be a doctor.’ I
have the utmost respect for nurses, but I didn't
like the idea of emptying bed pans [for a
living],” she laughed.

Now married to state Rep. Steven Jones and
expecting her first child in February, Dr. Jones
received a bachelor of science degree from
Dillard University in New Orleans. She
graduated from University of Arkansas for
Medical Sciences in 1993 and completed an internal
medicine residency there. She is the only full-time
physician working at East Arkansas Family Health Center.
Two part-time physicians and three nurse practitioners
help care for the indigent patients there. Many of Dr.
Jones’ patients cannot even afford the $15 it costs to visit
the clinic, she said.

“We are in the Delta, one of the poorest areas in the state
and probably one of the poorest in the nation. We see patients
every day who have to make a decision. Are they going to
buy their medicine, or are they going to pay their light bill?”
she said.

Dr. Jones is more
than a physician
at her East
Arkansas health
clinic. She’s a
friend, a social
worker and an
activist.

“MY MOTHER would always say, ‘If you can be a
nurse, then you can certainly be a doctor.’ ’’

Most patients lack the job skills or education to make a
decent living.

“Most of them spent their whole lives working on farms,
but farmers don’t need them to pick cotton anymore because
machines can do that. So what do you do if you can’t read or
write and all you’ve done is work on the farm?” she said.

Dr. Jones relies on donated
medicine and specialists’ services to
help ease the financial burden on
these patients, most of whom can be
referred to Memphis’ Baptist
Hospital, which Dr. Jones compares
to University Hospital in Little Rock.

“We all have to work in a concerted effort to take care of
the patients,” Dr. Jones said. But working at East Arkansas
Family Health Center means that Dr. Jones has to fill many
more roles than just that of a physician.

“There’s a big difference between working here and

being in private practice. You have to
be an activist. You have to be a social
worker. You have to be a friend. My
job is not just to diagnose and write a
prescription for somebody. In my
clinic, I have to ask [if the patient is]
going to be able to get this
prescription,” she said.

And underlying problems often prevent the patient from
taking his medicine properly, if he is able to afford it at all,
she said.

“The illiteracy rate here is astounding. When [patients]
aren’t taking their medicine right, you question if they can

84 • The Journal

Volume 97

read the label,” she said.

HIV and AIDS also is something
that Dr. Jones deals with on a daily
basis. Crittenden County ranks third in
the state for the number of reported
HIV and AIDS cases, according to the
Arkansas Department of Health’s HIV/
AIDS Surveillance report printed in
last month’s Journal.

A Title II grant that Dr. Jones
secured in 1998 allows her to provide
medical and social services to about
150 patients suffering from the deadly
disease.

But Dr. Jones doesn’t mean to leave
the impression that she’s bitten off
more than she can chew. In fact, she
would recommend working in this
setting to future physicians.

“I’m glad I had the chance to come
here fresh out of my residency. [In
school], we are not taught anything
about the business aspect of medicine,”
she said. At the clinic, Dr. Jones said
she is able to interact with financial,
insurance and medical department staff
members who are teaching her the
ropes in case she decides to go into
private practice.

“Coming back here has been
rewarding. It has made me appreciate
more of what I have and not to
complain so much, but I won’t say that
I will be here for the rest of my career,”
Dr. Jones said.

Dr. Jones was appointed in April
1999 by Gov. Mike Huckabee to serve
on the Governor’s Alliance for
Regional Excellence, a committee
comprised of leaders from southwest
Tennessee, northern Mississippi and
northeast Arkansas who are charged
with developing a plan to improve the
health and economic conditions of that
tri-state area. She also was appointed to
the state Board of Health in October
1999.

Dr. Jones is a member of the
Arkansas Medical Society and has
participated in the Doctor of the Day
program, volunteering her medical
services to state lawmakers during the
legislative session of 1 999.

She said that the Medical Society
has well-served its purpose as an
“advocate for physicians,” keeping
physicians across the state informed of
the laws that affect them and their
practices. ■

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Number 3

September 2000 • 85

Dermatology

Research

BY NATALIE GARDNER

r. Sandra Marchese Johnson loved
her residency in dermatology at the
University of Arkansas for Medical
Sciences, but is glad to now be a part
of the “real world.”

Her residency ended June 30, and July 1
marked Dr. Johnson's first day as an assistant
professor at UAMS and director of the
school's clinical trials unit in the department
of dermatology. As a young doctor. Dr.

Johnson has enjoyed a true diversity when it
comes to her medical education. In medical
school, the ratio of women and men was about
50/50, and in residency. Dr. Johnson worked
with more women physicians than men.

“We owe a lot to the women who came
before us,” Dr. Johnson said. “I still have some
patients who think I’m the nurse, and some
still want a male physician, but 95% of the
people I treat are fine with women physicians.”

Dr. Johnson, who is expecting her first child in January, is
keenly aware of the hurdles many women face.

“Women in medicine face the same things women in other
careers face — juggling being a wife, mother and a
professional,” she said.

Dr. Johnson always knew she wanted to be a doctor. Raised
in a blue-collar family, she wanted to use her intelligence and
talent to help others. She attended a six-year undergraduate/

“WE OWE a lot to the women who came
before us. I still have some patients who
think I’m the nurse, and some still want a
male physician.’’

Dr. Johnson

In 1996, UAMS" dermatology spends time in

program was one of eight programs at UAMS> new
that was a four-year residency, cosmetic and

integrating internal medicine with laser surgery

dermatology. Dr. Johnson was eager to center,
get in the program, and immediately
found a passion for research. As the director of the
department’s clinical trials unit. Dr. Johnson oversees seven
research programs. One of the largest
projects is a study of the treatment of
warts. The research includes using
immunotherapy to rid the body of the
virus that causes warts.

Aside from overseeing numerous

medical school program in Ohio and decided to specialize in
dermatology during her second year in medical school.

“With dermatology, you see patients of all ages,” she said.
“Also, the skin tells you everything that is going on; you can
see things getting better or worse. The skin also can tell us
when something is wrong on the inside, such as cancer or
diabetes.”

clinical trials. Dr. Johnson also spends
time in west Little Rock at UAMS' new
cosmetic and laser surgery center. She
helps patients with tattoo and age spot
removals, hair removal and chemical peels.

“I really like the cosmetic side of dermatology,” she said.
“I enjoy being able to use new treatments and be on the
cutting edge.”

And staying active in organized medicine keeps her on
the cutting edge too. Dr. Johnson said. Although busy in the
academic life. Dr. Johnson feels it's important for her to

86 • The Journal

Volume 97

stay active in groups such as the
Arkansas Medical Society and the
American Academy of Dermatology.
This year, she will serve as the
alternate delegate to the American
Medical Association for the AAD.
During her resident years, Dr. Johnson
was a strong voice for AAD residents
- across the country, serving as the
chairman of the Residents and Fellow
Committee in 1999. This year, she was
awarded the Presidential Citation for
Young Physicians in Dermatology by
the AAD.

“With the AAD, I was able to really
see how one person can make a
difference,” Dr. Johnson said. “We’re
looking at managed-care issues,
billing issues, patient education. Our
biggest issue right now is the Patients’
Bill of Rights.”

“With the AAD, I
was able to really see
how one person can
make a difference.
We’re looking at
managed-care issues,
billing issues, patient
education. Our
biggest issue right
now is the Patients’
Bill of Rights.”

Dr. Johnson said women are
gaining more and more power on the
political front, too. There are more
women serving as committee
chairmen and officers in the American
Medical Association.

As for her service in Little Rock,
Dr. Johnson said she plans to stay in
the research field, challenging herself
with new cases.

“I’ll be here for a long time,” Dr.
Johnson said. “I like the academic
environment, and I like where I work.
Unlike other physicians, we get to use
medicines that are a bit more risky and
not always available to the public
yet.” ■

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Number 3

September 2000 • 87

Dr Sidney

isi^wa

State Medicare
Medical Director

BY NATALIE GARDNER

ince January, Dr. Sidney Hayes has been sitting in
her office atop the USAble building, looking out
I on downtown Little Rock and smiling.

Before January, Dr. Hayes barely had five
minutes in the day to stare out the window and
contemplate her life. As the state’s Medicare medical
director. Dr. Hayes now has an 8-to-5 job that leaves
her time to go to her son’s baseball games, read,
collect Star Wars toys, go to bed at a decent time and
play in a rock ’n’ roll band. Before joining Arkansas
Blue Cross and Blue Shield, the insurance provider
that has the state’s Medicare contract. Dr. Hayes was
a pulmonologist in private practice for 15 years.

When in practice, she juggled raising three children,

17, 18 and 23, as a single mom with night and
weekend call.

“I was so tired and needed some rest, so this was a
good move for me,” Dr. Hayes said.

As medical director, Dr. Hayes oversees Medicare
policy and data analysis. Her department is constantly
running data on Medicare providers, looking for fraud
and abuse.

“The system kind of drives itself,” Dr. Hayes said.
“There’s a set of numbers and codes, and we’re
looking for any statistical changes.”

Dr. Hayes spends a good amount of time forming
state policy to fill the gaps when there are no national
regulations in place. When new procedures are developed,
Dr. Hayes and her staff decide how and if Medicare will
pay for it.

Hayes said. If a provider calls with a
particular problem and is wanting
Medicare coverage. Dr. Hayes and
her staff have to carefully consider
the situation.

When she’s not
overseeing the
state’s Medicare
program, Dr.
Hayes practices
with her rock ’n’
roll band.

“THE MOST important thing is to keep our
communication with providers open. We want
them to know we’re not out to get them.’’

“A typical day for me includes exchanging a lot of e-
mails with medical directors across the country,” she said.
“We also have many provider inquiries about coverage and
how to bill.”

Making exceptions for certain cases is always hard, Dr.

“The most important thing is to
keep our communication with
providers open. We want them to
know we’re not out to get them. Our
job is to protect the Medicare trust
fund.”

Dr. Hayes said fraud and abuse is
no more in Arkansas than anywhere
else. If there is a problem nationwide. Dr. Hayes often
sees it here too.

“We’re not any worse than any other state,” she said.
“I’m very pleased with the medical community here.”
Although she is a woman. Dr. Hayes said she garners

88 • The Journal

Volume 97

the same respect from the physician
community as any man.

“I haven’t had any prejudice in
my career,” she said. “The medical
director of the Health Care Finance
Administration is a female. Donna
Shalala [U.S. secretary of health and
human services], who is over her, is
a female. The top three people in
this area are all female. I don’t think
there’s any difference as long as you
do the work.”

When Dr. Hayes informed her
parents she wanted to be a doctor,
they were skeptical. She was the
first person in her family to go to
college, and Dr. Hayes’ mother
thought she might be doing a
“man’s job.”

“My parents had mixed feelings,”
she said. “I was going to go into
nursing, but took the MCAT on a
lark during my senior year, and
applied to medical school.”

But Dr. Hayes is quick to
recognize everyone’s talents, not
just women.

“You want anybody to be
successful, not just women,” she
said. “If we only helped women,
we’d be like the thing we are trying
not to be. That’s real important. I
don’t think it was harder being a
woman in medicine. Whoever the
best qualified is, that’s the important
thing.”

As a respected and busy
pulmonologist in Little Rock, Dr.
Hayes didn’t have a lot of free time
to keep up with medical issues.
That’s where the Arkansas Medical
Society helped.

“When you’re in practice, you
depend on the Medical Society to
look out for your best interest,” she
said. “I didn’t have time to follow
that, with a full-time practice and
three kids. They are great about
disseminating information we
need.”

Now, with more time on her
hands. Dr. Hayes spends every
Monday night practicing with her
band, made up of eight physicians
who are all in their early 50s.

“We play bar mitzvahs, birthdays,
you name it,” she said. “It’s like
being 20 all over again.” ■

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Number 3

September 2000 • 89

San Diego County General in 1965. She finished one year
of her residency at the same hospital before taking two
years off to have two children.

In 1968, the Chambers family moved to Little Rock,
where Dr. Chambers completed two more years of her
residency at UAMS. Her husband began an ear, nose and
throat residency there.

In 1969, the family moved to Shreveport, where Dr.

“At first I tried to limit my work to
school hours [so she could be home
with the children],” she said.

Extended family members and understanding
employees helped care for the Chambers children during
those erratic years. One time, a patient’s mother even
babysat while Dr. Chambers tended to the patient.

When her two youngest children turned 13, Dr.
Chambers began a full-time private practice, but the
schedule almost forced her into early retirement.

BY CHRISTY L. SMITH

omen now entering the medical
profession would do well to listen to
the advice of Dr. Sue Chambers.

The gentle-mannered assistant
professor of pediatrics at the University of
Arkansas for Medical Sciences has weathered
many storms during her 40-year career. She
overcame the prejudices of medical school
professors who claimed women students took up
class slots better filled by men, and she devoted
her life to caring for ill children in Boone County
while raising her own four children.

“I won’t say that I haven’t made mistakes
because I have,” she said. “I was lucky. I had
support.”

Dr. Chambers grew up in Gurdon, the oldest of
four children. Her father and grandfather, both
doctors, culled her interest in medicine. She
graduated from Hendrix College in 1960 and was
one of four women to graduate from UAMS' class
of 1964, with a total of 75 students.

Dr. Chambers and her husband. Dr. Carlton |
Chambers, met during their first year of medical 7
school and married soon thereafter. Pregnant when s
she graduated. Dr. Chambers planned to take a
year off before seeking an internship in San Diego,
where her husband was stationed in the U.S. Navy. But
their first child, who was born prematurely, died. Dr.
Chambers said she then stumbled into pediatrics.

“Pediatrics was not a popular specialty then, and I didn’t
have anything lined up for that year,” Dr. Chambers said.

Dr. Chambers completed her internship in pediatrics at

“I WONT say that i haven't made mistakes
because I have. I was lucky. I had support.”

Dr. Chambers
has watched as
attitudes toward
women

physicians have
turned 180
degrees.

Chambers completed the final year of
her residency and taught at Louisiana
State University.

“[Today’s] students can’t move
around as much now as I did then.

The only reason I was able to find

residencies in all those places is that
not many people wanted to be a
pediatrician,” she said.

In 1973, the family moved once
more — to Harrison.

Pediatrics

90 » The Journal

Volume 97

“The winter before I left, I worked
an average of 14 hours a day, seven
days a week. We lost some family
practice physicians in the area, and I
had to take on more children,” she said.

Relief came in 1998, when Dr.
Chambers’ husband accepted a faculty
position at UAMS. She took an
assistant professor post, which allows
her to work from 8 a.m.-5 p.m. most
days and frees up her weekends.

“I wasn’t able to help my daughter
with her children [when they were
smaller], but now I keep the
grandchildren on the weekends,” she
beamed.

Dr. Chambers marveled at how
much the medical field has changed
over the last 40 years, particularly in
its attitude toward women physicians.

“A lot of things have been done to
accommodate the married woman.
New mothers [students and residents
included] get six weeks maternity
leave. The fathers even get a few days
off,” she said. “If I had had a baby
when I was in medical school, I
would have been expected to repeat a

year if I took time off. Now mothers
can leave and pickup where they left
off.”

Dr. Chambers concedes, however,
that it remains difficult for women
physicians to juggle family
obligations with a successful career,
and she often tells female students
“to just look at the situation available
and make the best possible solution
to their problem.”

“Everybody has to solve that
problem in their own unique manner
...Be flexible. Don't look at
something and say you can’t handle
it because you never know what
solution will present itself,” she said.

Dr. Chambers and her husband
maintain a home in Harrison and plan
to retire there to be near their
pharmacist daughter. All three
Chambers’ boys have chosen arts-
related careers — one is a dancer in
New York, another will earn his
doctorate in medieval drama at Trinity
College in Dublin, Ireland, this fall,
and the third is a business manager for
a Fayetteville advertising firm.

Dr. Chambers was a long-time
member of the Boone County Special
Services School Board and the Health
and Social Services Advisory
Committee for Headstart. She was
appointed to the state Medical Board
in 1998 and is a member of the
Arkansas Medical Society.

She noted that women have
become more active in the Medical
Society over the last 40 years.

“The Medical Society is one of
the last venues that women have
become active in because they have
been trying to gain more credibility
and success in their careers. ... [And]
we haven’t made a drastic change, but
we have made the society more
community-minded. The society has
always been interested in the health
of our patients, but women have
probably gotten the society more
interested in family matters such as
battered women, children and youth,”
she said.

Dr. Chambers predicts that women
will continue “to be very active and
influential in the society.” ■

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Number 3

1 1

September 2000 • 91

Obstetrics and
Gynecology

BY CHRISTY L. SMITH

r. Brenda Powell has lost count of the number
i of babies she’s delivered during her 20-year
' career as an obstetrician and gynecologist at
Physicians for Women in Hot Springs.

“After 20 years, it must be more than 2,000,” she
said, her eyes widening as the impact of that statement
begins to sink in.

An inches-thick photo album and framed
photographs displayed on the credenza in her office
keep many of those babies at the forefront of Dr.

Powell’s memory, and returning patients often bring
their children in to meet the doctor who delivered them.

Born and raised in Harrison, the 52-year-old
physician attended Arkansas Polytechnic College (now
Arkansas Tech University) in Russellville and the
University of Arkansas at Fayetteville before earning a
bachelor of science degree in biology and chemistry in
1976 from the University of Arkansas at Monticello.

She moved around because her husband’s work as an
Episcopal priest demanded it. Fess Powell is now
retired.

“There were times I didn’t think I would get
enough credit hours in one place to graduate,” she
said.

But Dr. Powell graduated cum laude and entered the
University of Arkansas for Medical Sciences in fall 1976.
Dr. Powell said she had nothing but support from her
husband during her grueling four years of medical school.

“He got out a clip board and pen and asked me to show
him how to use the washer and dryer. He stood there and

“YOU NEVER come to the office and feel like
you’re doing the same thing.”

wrote it all down [because] he knew somebody had to do his
laundry, and it wasn’t going to be me for awhile,” she
laughed.

The only woman in UAMS’ class of 1980, Dr. Powell
said she also enjoyed support from medical school
professors and classmates. In fact, “if I did my job, I always
had a friendly reception,” she said.

Dr. Powell completed an OB/GYN residency at UAMS

Dr. Powell

in 1984 and immediately went to was the .on*y

J woman in her

work with a colleague at Physicians 1 930 medical

for Women. She now works with three school class.

physician partners and two nurse

practitioners. Dr. Powell said she

loves obstetrics and gynecology because it is an all-

encompassing specialty that allows
her to perform everything from
general care to surgery.

“You never come to the office and
feel like you’re doing the same
thing,” she said.

In addition to her daily roster of
about 30 patients, ever-changing technology and managed
care keep Dr. Powell on her toes.

“The medicine we practice today is not the medicine we
practiced 20 years ago,” Dr. Powell insisted.

Ultrasound, which today produces a near portrait of the
baby, could only determine whether a baby was breached
20 years ago, and Caesarean sections and epidurals are
more common today, Dr. Powell said.

92 • The Journal

Volume 97

“I go to meetings now, and I see all kinds of
people in all kinds of dress. The Society really
represents a whole spectrum of people now.”

But attitudes about child birth also
have changed. It is now common for
extended family members to witness
the birth, and the father-to-be is
always in the delivery room when his
child is being born.

“I hardly ever have one pass out
anymore,” Dr. Powell laughed.

To keep up with the changes in her
profession. Dr. Powell attends
continuing education classes and
professional conferences — nearly 60
between 1987 and 1999.

But those classes rarely prepare her
for the problems associated with
managed care. Dr. Powell said she is
often caught between increasing the
quality of a patient’s life and what an
insurance company will pay for.

“A good example is a woman who
needs a hysterectomy just to have a
better quality of life. The insurance
company doesn’t consider the situation
life-threatening, so many obstetricians
find themselves in the way of the
insurance company,” she said.

The Arkansas Medical Society has
proven to be an invaluable advocate

for physicians, particularly in the face
of increased scrutiny from managed
care organizations, Dr. Powell said.

And the Society’s willingness to
grow and change over time has lended
it more credibility with the physicians
it serves, she said.

“I remember my first [Medical
Society] meeting at the Arlington
Hotel [in Hot Springs]. I was one of
two women physicians in the room.
Every man had on a dark suit and tie
and stood up anytime a woman
walked into the room,” she
reminisced.

Dr. Powell said she met “a whole
bunch of people” who made her feel
welcome that day, but she’s glad the
Society has become more inclusive.

“I go to meetings now, and I see all
kinds of people in all kinds of dress.
The Society really represents a whole
spectrum of people now,” she said.

Since joining the Medical Society
in 1985, Dr. Powell has served as a
district councilor, second vice president
and vice speaker to the House of
Delegates. She also is a member of the
Garland County Medical Society, the
American Medical Association and a
diplomate to the American Board of
Obstetricians and Gynecologists.

Dr. Powell said her work schedule is
never normal, and she still gets phone
calls in the middle of the night. But her
never-complaining husband and the
occasional post-birth cigar make it all
worth it, she said.B

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Number 3

September 2000 • 93

Family Practice

BY CHRISTY L. SMITH

For most busy professionals, a two-week
vacation brings a welcome respite from
the hectic pace of their careers. But Dr.

Anna Redman enjoys working vacations —
ones in which she delivers medical care and
evangelizes to poverty-stricken people across the
world.

“I enjoy going door to door presenting the
Gospel to people and learning more about the
way medicine is practiced in other countries,”
said the 41 -year-old family practice physician
from Pine Bluff.

Dr. Redman and her husband of 1 1 years. Dr.

John Redman, chairman of urology at the
University of Arkansas for Medical Sciences,
travel with organizations affdiated with the
Southern Baptist church. The couple have been
to Russia, Kenya, England and New Zealand.

They leave Oct. 1 for Suriname, the former
Dutch Guyana in South America.

“This is the first time we will be doing a true
jungle ministry. It will be the most primitive
setting we’ve been in. We can't shower for a
week, but at least we will have drinking water,” 1
Dr. Redman said. J

The Redmans will join a Southern Baptist
missionary in a small jungle village about two
hours from the country’s capital, Paramaribo, and spend 10
days teaching basic hygiene and evangelizing to villagers.
Born and raised in Pine Bluff, Dr. Redman said she has

chemistry from Hendrix College. She
graduated from UAMS in 1984, one
of about 20 women in a class of 140.

“I did not

Mission trips to
far-away lands
are the norm
for Dr. Redman
and her doctor
husband.

“THIS IS the first time we will be doing a true
jungle ministry. It will be the most primitive
setting we’ve been in. We can’t shower for a
week, but at least we will have drinking water.”

always been interested in science and gravitated to
medicine for the job security that it offers.

“I wanted to be able to support myself in a career that
would not become obsolete,” she said.

Dr. Redman earned a bachelor of arts degree in

have a lot of
female role

models when I was in medical
school. My college roommate was
one year ahead of me, and she
helped me along,” Dr. Redman said.

Following an internship and
residency in family practice at Area
Health Education Center in Pine
Bluff in 1987, Dr. Redman joined
Family Medicine Associates. She has one physician
partner and sees about 30 patients a day, practicing all
aspects of family medicine except surgery and obstetrics.
Unlike many family practitioners, Dr. Redman also does
a fair amount of counseling because she said that a

94 • The Journal

Volume 97

“physical ailment often goes much
deeper.”

She said that when she began
practicing medicine, her male col-
leagues were generally accepting of
her. However, patients were some-
times leery of going to a woman
physician.

“There was still some of the good-
old-boy system [in the profession], but
women physicians had more of a
problem overcoming patient preju-
dices because [patients] weren't
accustomed to seeing a female physi-
cian,” she said.

And many male members of the
Arkansas Medical Society welcomed
her with open arms. Dr. Redman said.

“Dr. Crenshaw, Dr. Langston, Dr.
Logan and Dr. Jim Weber [were] all
people who were real supportive of
women in the society,” she said.

Since joining the Medical Society
in 1987, Dr. Redman has served as an
alternate delegate and delegate from
Jefferson County, second vice presi-
dent, 4th district councilor and is
currently speaker of the House of
Delegates. She also has chaired the
Young Physicians Committee and was
an alternate delegate to the AMA.

The number of female Medical
Society members has increased just in
the last 13 years, and Dr. Redman
feels these women can help the society
become more inclusive.

“Women tend to be very team-
oriented and don’t necessarily have to
be in charge, which easily facilitates a
wider variety of people being included
[in the society],” she said.

But Dr. Redman’s attitude of
acceptance reaches beyond the scope
of the Medical Society. She insists that
people are basically the same whether
they live in a hut in Kenya or a posh
home in west Little Rock.

“In Kenya, everyone is very polite
and very considerate of other people,”
she said.

“We often think those people have
less than we do, but in a lot of ways
they are richer than we are . . . [ When
telling them about the Gospel], their
questions are the same as when we
talk to people in west Little Rock.
Mission work really opens your eyes
to the fact that people are pretty much
the same all over the world.” ■

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Number 3

September 2000 • 95

LOSS PREVENTION

A Baseline Is Necessary

J. Kelley Avery, MD

At 2:30 a.m.
the nurse’s
note

described
"cyanotic
fingertips.”
While this
observation
was being
made, the
patient
suddenly
became
pulseless and
stopped
breathing.
Cardiac
resuscitation
was begun
and about
three minutes
later her
pulse

returned and
she spoke to
her family.

The 42-year-old patient was the mother of
two children, both adults. She had been
complaining of “something falling out” of her
vagina for more than a year. The complaint
was accompanied by a feeling of pressure low
in the abdomen. Her menses had become
increasingly excessive for the past several
months, and she was incontinent when she
strained or coughed. Except for this, she felt
well. She had not lost weight and had a good
appetite and knew of no other problems.

She had discussed her complaints with her
OB/GYN on her two visits during the past few
months. The doctor did a complete physical
examination and found nothing except that
her cervix was visible at the vaginal introitus
and that she passed some urine on straining.
The examination revealed no adnexal
pathology, and the uterus did not seem to he
enlarged. Her annual Pap smears had been
negative for years. After her surgeon discussed
the options with her, they agreed that a vaginal
hysterectomy with an anterior and posterior
repair was the treatment of choice.

The patient was admitted to the hospital
in the early morning of the day of surgery. The
preoperative laboratory tests showed a WBC
count of 6,700/cu mm with 58% segmented
neutrophils, 7% eosinophils, 1% basophils,
31% lymphocytes and 3% monocytes. The
urine was entirely negative. She was taken to
surgery that morning, where a routine vaginal
hysterectomy and anterior and posterior repair
was done. She tolerated the procedure well and
went to the recovery room with normal vital
signs and was beginning to wake up.

The OB/GYN surgeon’s postoperative
orders included an open IV of D5W set to run
at 1 10 drops per minute. She was given a broad-
spectrum antibiotic, and Demerol was
prescribed for pain. On the evening of the
surgery, the patient experienced some nausea
for which Vistaril was ordered as needed. The
following morning the vaginal pack was
removed. She continued to be nauseated and
vomited on at least two occasions. Vistaril was

replaced with Valium 5 mg as needed for
nausea, and morphine given for pain.

At 1:45 a.m. the surgeon examined his
patient and noted that she was “very restless
but breathing good. No bleeding. Appears to
be having a reaction to medication.” At 2:30
a.m. the nurse’s note described “cyanotic
fingertips.” While this observation was being
made, the patient suddenly became pulseless
and stopped breathing. Cardiac resuscitation
was begun and about three minutes later her
pulse returned and she spoke to her family.
She was taken to the ICU, where a
consultation with a cardiologist was requested.

A short time later — perhaps 15 minutes
— she had a heart rate of 140/min, was
hypotensive and fine twitching of the muscles
was noted. Blood taken immediately after the
resuscitation showed a pH of 7.29, PO, 173
mmHg while breathing 100% oxygen, and
PCO, 43 mmHg. The sodium was reported at
120 mEq/L and the potassium 3.0 mEq/L.
Blood studies again obtained at 3 a.m. showed
the sodium at 114 mEq/L, the potassium 2.9
mEq/L, chloride 75 mEq/L, and COz 17. The
IV of D5W was replaced with 3% sodium
chloride to run 500 cc every two hours. She
had received between 5,000 and 6,000 cc of
the glucose solution.

By 5 a.m. the patient was unresponsive
and her pupils were dilated and fixed. Two
hours later the sodium was reported at 137
mEq/L. She was seen by other consultants in
an attempt to evaluate the profound diuresis
that occurred after the hypertonic saline. The
BUN and creatinine were normal. Their
collective opinion seemed not to consider the
large volume of D5W she received as being
significant.

After spending the next six days on a
respirator, she was determined to be brain dead
and life support was stopped. No autopsy was
done.

A lawsuit was filed charging the surgeon
with negligence in not monitoring
electrolytes either before or after surgery

96 • The Journal

Volume 97

while giving the large volume of D5W.

Loss Prevention Comments

During the investigation of this
case, it was troublesome that the
electrolytes were not routinely checked
preoperatively by this surgeon,
attributing the restlessness to
medication without covering all the
bases was an error in judgment.

From the record, it does not appear
that any of the team appreciated that
such a large amount of D5 W had been
given. There was an exhaustive
investigation to rule out central
nervous system disease, renal disease
and the like without coming to grips
with the fact that the most logical
solution was water intoxication
resulting in severe hyponatremia. Her
restlessness was an expected reaction
to this problem, and had it been
correctly diagnosed and treated at that
time, the outcome might have been
favorable. It was the cerebral edema
resulting from the hyponatremia and
hypokalemia that produced the
restlessness and ultimately the
cardiorespiratory depression and
cardiac arrest. Once the cascade of
events began, it progressed rapidly, and
by the time the electrolyte imbalance
had been corrected, the cerebral
hypoxia had exacted its toll and the
patient was doomed to continue on a
downhill course. One feels for the
treatment team, especially the surgeon.
He was at the bedside during the
deterioration of his patient, focused, it
appears, in the wrong direction.

Without a preoperative electrolyte
study with a postoperative follow-up,
the physician was in the dark. Baseline
preoperative studies are essential to
proper postoperative care. ■

The case of the month is taken from
actual Tennessee closed claims. An
attempt is made to fictionalize the material
in order to make it less easy to identify.
Dr. Avery is a member of the Loss
Prevention Committee, State Volunteer
Mutual Insurance Co., Brentwood,
Tenn. This article appeared in the August
1999 issue of Tennessee Medicine. It is
reprinted with permission

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Number 3

September 2000 • 97

Pulmonary Hypertension
in Pregnancy

Steven E. Kelley, MD Eugene S. Smith, III, MD, Editor

The combination of pulmonary
hypertension and pregnancy can lead to
maternal/ fetal death. Pulmonary

hypertension can be either primary
(idiopathic) or secondary. In the case of
primary pulmonary hypertension (PPH),
its incidence rate is 1-2 per million. PPH
tends to occur in young females between the
ages of 20-40. Secondary pulmonary
hypertension may be related to underlying
cardiac or pulmonary disease, recurrent
thrombo-embolic episodes , drugs, etc. This
case highlights several important issues in
the management of pulmonary hypertension
during pregitancy .

Case Report

A 25-year-old white female gravida4
paraj abortion2 now at 35 weeks gestation
transferred from an outside hospital for
further management of pregnancy
complaining of worsening shortness of
hreath and dyspnea on exertion (DOE).
The patient reports a normal vaginal
delivery approximately four years ago, hut
since that time, she has had progressive
DOE. She was seen hy her local doctor
shortly after delivery who attributed her
symptoms to residual weight from
pregnancy. She denies paroxysmal
nocturnal dyspnea, orthopnea or cyanosis.
During this pregnancy, she reports that
her DOE has progressively worsened. On
initial evaluation at the outside hospital,
her oxygen (0,) saturation on room-air
was in the mid 80s. This corrrected to

>92% by the use of supplemental 0,. At
the outside hospital, an echocardiogram
revealed a dilated right atrium and
ventricle with severe tricuspid
regurgitation and moderate pulmonary
regurgitation. The estimated right
ventricular systolic pressure was >
90mmHg. A bubble study was suspicious
for a small patent foramen ovale.

Her past medical history was
significant for obesity and exposure to
hepatitis C; she had smoked one to two
packs per day for the last seven years. She
had no prior cardiac history and denied
use of either diet pills or illicit drugs.

Physical examination revealed a
young white female in mild respiratory
distress. Her blood pressure was 114/60
mmHg with a pulse of 90 beats/minutes
and weight of 202 pounds. Jugular venous
pressure could not be assessed. Cardiac
examination demonstrated a right
ventricular heave, laterally displaced
apical impulse. A prominent pulmonary
component of the second heart sound,
and a grade 2/6 systolic murmur heard best
at the left lower sternal border. Lungs were
clear. Extremities showed no edema,
cyanosis or clubbing.

After transfer to our facilities, the
patient was admitted to labor and delivery
and placed on telemetry monitoring.
The supplemental 0, was continued, and
she remained clinically stable.
Laboratory evaluation revealed a
hemoglobin of 14 g/dl, hematocrit of

42% and normal electrolyte panel. HIV/
Hepatitis panel were negative. On
hospital day four, she was transferred to
the intensive care unit for induction of
labor with the use of oxytocin. An arterial
and central venous pressure line were
placed. The patient had spontaneous
rupture of the membranes, and after 3.5
hours of labor, an uncomplicated vaginal
delivery of a healthy female infant. She
was continued on supplemental 0, and
started on oral anticoagulation. The
patient did well after delivery, hut on post-
partum day two developed increased SOB
with 0, saturation in the 80s on 6L. The
possibility of pulmonary artery embolus
was entertained but a spiral CT of the
chest was negative. The patient
improved and was discharged home on
post-partum day four on oral warfarin and
off supplemental 0,. The patient was
scheduled to follow-up in cardiology
clinic in one month for further
evaluation and treatment of pulmonary
hypertension.

Discussion

Pregnancy in the setting of severe
pulmonary hypertension has been
associated with a high mortality rate. In
an overview by Weiss, et al1; it was
estimated that pregnancy in patients with
PPH had a maternal mortality of 30%.
In patients with Eisenmenger’s syndrome,
the mortality was 30-4 0%, and patients
with secondary vascular pulmonary

98 • The Journal

Volume 97

hypertension the mortality was greater
than 50%. The mortality in these patients
is noted to be the highest in the first 30
days post-partum.

The diagnosis of pulmonary
hypertension can be delayed due to the
difficulty in distinguishing symptoms from
normal physiological changes of
pregnancy. As with all diagnosis, a
thorough history and physical is
important. Some of the key features of
the history include known congenital
heart defects, underlying lung disease,
smoking, cocaine use or use of diet drugs.
In addition to the history and physical, a
high index of clinical suspicion for
possible underlying pathology is required.

The diagnostic work-up for
pulmonary hypertension should include
investigation for any possible secondary
causes. The most common secondary
causes are related to cardiac or pulmonary
abnormalities. Echocardiography allows
for assessment of underlying cardiac
function, valvular abnormalities, cardiac
defects and estimation of the severity of
pulmonary hypertension. Other
diagnostic tests includes electrocar-
diogram, pulmonary function tests,
ventilation perfusion scan, lower
extremity dopplers and drug screen. In our
patient, we were not able to fully assess
her for secondary causes because of her
presentation late in pregnancy.

The management of these patients
during the peri-partum period should be
a multi-disciplinary approach, including
an obstetrician, anesthesiologist and a
cardiologist.2 Due to the rare number of
cases, there is no large randomized trial
on the treatment of these patients.
Physicians managing these patients would
agree on supplemental 0, to keep
saturation greater 90%, anti-coagulation
with heparin (either low-molecular wt.
or unfractionated), ECG monitoring and
keeping fluid balance during the pre-
partum period.2

The mode of delivery (vaginal vs.
cesarean section) is usually dictated by the
obstetrical need. There have been reports
in the literature that patients may actually
do worse with cesarean section. Thus
most authors advocate vaginal delivery if
possible. Epidural anesthesia is most
commonly used in these patients.

The use of nitric oxide (inhaled) and

prostacyclin (IV/inhaled) in the peri-
partum period is increasing.3’4 5 Both of
these vasodilating substances are
decreased in patients with pulmonary
hypertension due to endothelial cell
dysfunction. In addition, endothelin levels
are increased leading to vasoconstriction.
Preliminary data with the use of these
substances is promising, but their use is
still in the investigational stages.

Anticoagulation should be started as
soon as possible after diagnosis unless
contra-indicated.1,2 The use of heparin
(either low-molecular wt. vs. unfraction-
ated) in the pre-partum is usually the rule.
Post-partum the patient can be changed
to warfarin therapy.

Conclusion

The combination of pregnancy and
pulmonary hypertension can be lethal.
The early diagnosis of this condition plays
a key role in the outcome of these patients.
The management of the patient requires
a multi-disciplinary approach. The patient
should be counseled against any
subsequent pregnancy. ■

References

1. Weiss BM, Zemp L, Seifert B, Hess
OM. Outcome of pulmonary vascular
disease in pregnancy: A systematic
overview from 1978 to 1996. J Am
Coll Cardiol 1998;31:1650-7.

2. Smedstad K, Cramb R, Morison D.
Pulmonary hypertension and
pregnancy: a series of eight cases.
CanJ Anaesth 1994;41:502-12.

3. Robinson J, Banerjee R, Landzberg
M, Thiet MP. Inhaled nitric oxide
therapy in pregnancy complicated by
pulmonary hypertension. Am J
Obstet Gynecol 1999;180(4): 1045-46.

4. Goodwin T, Gherman R, Hameed
A, Elkayam U. Favorable response
of Eisenmenger syndrome to inhaled
nitric oxide during pregnancy. Am J
Obstet Gynecol 1999; 180( 1 ):64-67-

5. Easterling T, Ralph D, Schmucker B.
Pulmonary hypertension in
pregnancy: treatment with pul-
monary vasodilators. Obstet Gynecol
1999;93:494-8.

6. Kiss H, Egarter C, Asseryanis E, Putz
D, Kneussl M. Primary pulmonary
hypertension in pregnancy: A case
report. Am J Obstet Gynecol
1995;172:1052-4.

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Number 3

September 2000 • 99

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PEOPLE+EVENTS

RETIREMENT

Dr. Harry Ward
Leaves UAMS Post

Dr. Harry Ward,

chancellor of the University
of Arkansas for Medical
Sciences for 21 years,
announced his retirement,
effective Dec. 3 1 .

Dr. Ward, 67, is credited
with transforming UAMS
into a nationally recognized
institution known for its
cutting-edge research, inclu-
ding construction of the
Arkansas Cancer Research
Center, the Jones Eye Institute
and the Reynolds Center on
Aging. UAMS’ multiple
myeloma center is considered
one of the best in the world,
drawing patients from across
the world. University Hospital
was listed in the top 50 in four
categories in the most recent
U.S. News and World Report
hospital rankings.

During his time, Dr. Ward
oversaw more than $200
million in construction
projects on the campus. The
campus has increased fivefold
and has become one of the
state’s largest employers, with
nearly 8,000 employees.

Dr. Ward is an internist
with an emphasis on hema-
tology. Although he hasn’t
been in practice for about 15
years, he still visits patients in
University Hospital’s inten-
sive-care unit and is still
consulted by other physicians
on challenging cases.

Dr. I. Dodd Wilson,
executive vice chancellor,
dean of the College of
Medicine and a professor in
the department of medicine,
will replace Dr. Ward as

chancellor. He will assume the
position Oct. 16.

Dr. Wallace Retires
After 42 Years

Dr. Oliver Wallace, a

family practice physician in
Green Forest, recently retired
after 42 years in practice.

The 68-year-old physician,
who graduated from medical
school in 1956, was honored
in two receptions held June 18
at Green Forest United
Methodist Church and June
30 at his Green Forest Clinic.

An active member of his
profession, Dr. Wallace served
1 2 years on the PRO Board, a
medical review board for
Medicaid and Medicare, was
president of the American
Academy of Family Physicians
and was a councilor for the
Arkansas Medical Society.

During his tenure in Green
Forest, Dr. Wallace helped
establish a nursing home in
Berryville, start a family
planning clinic, secure the
building for the local health
department clinic and start
home health services in Carroll
County. In addition, Dr.
Wallace lended his support to
initiating a Meals on Wheels
program and transportation
services for the elderly.

Dr. Wallace’s plans for the
future include travel, honing
his computer skills, developing
a cookbook for men and
painting.

HONORED

AMA Names
PRA Recipients

Each month the American
Medical Association presents
the Physician’s Recognition

Award to those who have
completed acceptable programs
of continuing education.

AMA recipients for April
include Dr. Roy D. Coleman
of White Hall, Dr. Kenneth
P. Collins of Harrison, Dr.
Rebecca R. Floyd of Van
Buren, Dr. Edward J. Jones
of Batesville, Dr. Glen C.
Knowles of Bradford, Dr.
Albert S. Koenig of Fort
Smith, Dr. Elvin L. Norris of
Beebe, Dr. Robert L. Prosser
of McGehee, Drs. Jonathan
M. Cook and Lynda B.
Milligan of North Little Rock,
Drs. Robert L. Kerr and
Kenneth M. Kilgore of
Mountain Home and Drs.
James Z. Mason and David R.
Rozas of Little Rock.

OBITUARY

Fredric J. Sloan, MD

Dr. Fredric J. Sloan, 77,

of Batesville died March 7.

Born in Walker, Iowa, Dr.
Sloan was a retired general
surgeon.

Dr. Sloan received a
bachelor of science degree at
Coe College in Cedar Rapids
and attended the University of
Iowa School of Medicine. He
practiced medicine for 30 years
in Cedar Rapids and for five
years at Sullivan, 111.

Survivors include four
sons, Dr. Fredric J. Sloan II of
Eureka Springs, Steve Sloan of
Cedar Rapids, Michael Sloan
of Batesville and Dr. Luke
Sloan of Hood River, Ore.; two
daughters, Patricia Perkins of
Seattle and Jody Murphy of San
Francisco; a brother, Dr. Jim
Sloan of Independence, Iowa;
the mother of his children,
Marilyn Miller of Hot Springs;
12 grandchildren; and three
great-grandchildren.

He was preceded in death
by his parents and wife, Lynn
Hodges Sloan. ■

Resolution

Walter J. Wilkins Jr., MD

WHEREAS, the members of
the Jefferson County Medical
Society are deeply saddened by the
death of an esteemed member,
Walter J. Wilkins, Jr., M.D.; and

WHEREAS, Dr. Wilkins
demonstrated his dedication to his
profession by many years of
membership in this Society, the
Jefferson County Medical Society,
and as a fellow of the American
College of Surgeons, and

WHEREAS, Dr. Wilkins’
patriotism was evidenced by his
service in the Army Medical
Corps from 1945 to 1947,
stationed with the occupation
troops in Japan and

WHEREAS, Dr. Wilkins
utilized his leadership abilities in
positions such as Director of
Medical Affairs and Chief of
Surgery at Jefferson Regional
Medical Center, and

WHEREAS, Dr. Wilkins
inspired thousands of medical
students as an instructor for the
University of Arkansas Medical
School Department and as an
associate clinical surgery professor
at the University of Arkansas for
Medical Sciences; and by helping
develop the baccalaureate nursing
program at the University of
Arkansas at Pine Bluff and the
associate nursing degree program at
the University of Arkansas at
Monticello.

BE IT THEREFORE RE-
SOLVED:

THAT, this resolution be
adopted and placed in the archives
of the Society; and

THAT, a copy be sent to Dr.
Wilkins’ family as an expression of
our sincere sorrow; and

THAT, a copy be made
available to the The Journal of the
Arkansas Medical Society for
publication.

Number 3

September 2000 • 101

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Arkansas Financial Group Inc., The 102

Arkansas Foundation for Medical Care Inside front cover

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Central Flying Service 85

Employers Healthcare Resources Inc 81

Guest House Inn 87

HealthLink of Arkansas 95

Helena Regional Medical Center 89

Little Rock Medical Association 97

Maggio Law Firm 91

Medical Protective Co., The 100

Metropolitan National Bank 89

PhyAmerica Physician Services Inc 87

Riverside Motors 75

St. Paul Medical Services 93

Smith Capital Management 95

Snell Prosthetic & Orthotic Laboratory 76

Southwest Capital Management Inc 81

State Volunteer Mutual Insurance Co Back cover

Special Publications

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Editorial Art Director

Editon in -Chief

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Natalie Gardner
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Advertising Art Director
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Christy L. Smith

Advertising Coordinator

Sales Manager
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Marketing Assistant

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Volume 97

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Volume 97 Number 4
October 2000

Journal

OF THE ARKANSAS MEDICAL SOCIETY

Winner of the ASAE Excellence in Communications Award

CONTENTS

FEATURES

115 The Big Easy

Arkansas physicians are retiring early in the face of increased
managed care headaches and long hours .

120 Advocating for Breast Cancer Awareness

Dr. Michael Cross of Fayetteville is a champion of breast
cancer research and awareness. As a member of the state’s
Oversight Committee on Breast Cancer Research, Dr. Cross
fights to give money to those making headway in finding a cure.

An increasing number of Arkansas
physicians are leaving their practices
to pursue other interests.

— page 115

123 State Senator Honored

State Sen. Jay Bradford was named as the American Medical
Association’s winner of the Nathan Davis Award, which
recognizes those in government who are fighting for public
health and the medical field.

DEPARTMENTS

111 Commentary

125

Radiology Report

William E. Ackerman, III, MD

128

Cardiology Report

113 What We’ve Done

135

People + Events

For You Lately

137

Arkansas Retreats

124 Loss Prevention

138

Index to Advertisers

Dr. Thomas A. F ormby is DAMS’
Distinguished Alumnus for 2000.

— page 135

Number 4

October 2000 • 109

protects you

7-650-AFMC

Arkansas Foundatic
for Medical Care

COMMENTARY

Internet Information is
a Double-edged Sword

William E. Ackerman, III, MD

Because medical information can now be obtained from
Internet sources, physicians are occasionally caught
off guard by those patients who have information
about their diseases that their physicians
know nothing about. On the other hand,
physicians can spend considerable time
with patients countering false opinions
and medical claims obtained from the
Internet.

The Internet is a large system of
connections between a vast number of
computers. One connects to the Internet
by an Internet Service Provider (i.e.,

America Online) using a telephone
modem. Once connected to the Internet,
a web site must be contacted. A web site (
i.e., www.WebMD.com) is a collection of
files on a web server computer that is
connected to the Internet and sends
information to other computers on the
Internet by special communication
methods.

A web browser (i.e., Netscape) is a
computer program that enables one to
view information obtained from the
Internet that is written in a standard
format called Hypertext Markup Language
(HTML). The World Wide Web (WWW)
is a subsection of the Internet. The World
Wide Web is the most popular section of
the Internet and can present information
in a multimedia format. A web site is found
by using software referred to as a search
engine (i.e., Yahoo). A search engine
performs specialized searches for
information found on various web sites and places the
information in a well-indexed directory.

Because of the Internet and various web sites, medical
reports, medical news and many medical journals are now
accessible to anyone who has access to a computer and
modem. Many electronic health web sites offer not only
basic general health information but also highly technical
information (The National Institute of Health’s National
Library of Medicine).

Today there is a great demand from patients for

medical literature. A problem faced by many physicians
is the reliability of the data available. Many patients come
to a physician’s office with a multitude of pages printed
from various web sites. Many patients do
not realize that treatment suggestions
presented on some web sites are by no
means uniformly effective. There is a
tendency for some individuals who have
little faith in traditional medicine to
rely on web sites, many of which offer
treatment suggestions that offer little or
no scientific basis.

Patients do not always understand
the ambiguity in the medical literature.
A patient may expect a definitive answer
to a particular disease. The American
Medical Association is helping
physicians set up customized web sites
that will enable patients to access
credible medical literature, ranging in
format from a junior high school level
to a more sophisticated level.

Even with this information a double-
edged sword still exists because the
therapeutic information extracted from
the physician’s web site may not be
applicable to a particular patient.
Patients must be aware that the art of
medicine involves a physician’s awareness
of both the pathophysiological and
psychopathological problems encoun-
tered. A physician, unlike a weh site, has
access to a range of medical, physical and
psychological therapies for many disease
entities based upon the results of a
patient’s history, physical examination and laboratory and
imaging studies. The practice of medicine is an art and is
much more than the application of scientific knowledge
to a particular pathologic occurrence. The Internet is useful
when it helps patients understand their diseases but becomes
a nuisance when they use it to dictate their care. ■

Dr. Ackerman is an anesthesiologist/pain management
specialist in Little Rock and a member of The Journal of the
Arkansas Medical Society editorial board.

"The Internet is
like a tidal wave
which will wash
over the computer
industry and many
others, drowning
those who don't
learn to swim in
its waves."

— Bill Cates, founder
of Microsoft

Number 4

October 2000 • 111

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COMMUNICATIONS COORDINATOR

Judy Hicks

EXECUTIVE VICE PRESIDENT

Kenneth LaMastus, CAE

ASSISTANT EXECUTIVE VICE PRESIDENT

David Wroten

EDITORIAL BOARD

Jerry Byrum, MD
Joseph M. Beck, II, MD
Lee Abel, MD
Samuel Landrum, MD
Jerry Kendall, MD
William Ackerman, MD

Pediatrics
Oncology
Internal Medicine
Surgery
Family Practice
Anesthesiology

EDITOR EMERITUS

Alfred Kahn Jr„ MD

ARKANSAS MEDICAL SOCIETY
2000-2001 OFFICERS

Gerald A. Stolz, Jr., MD, Russellville
President

Joe Stallings, MD, Jonesboro
President-elect

Paul A. Wallick, MD, Monticello
Vice President

Lloyd G. Langston, MD, Pine Bluff
Immediate Past President

Carlton L. Chambers, II I, MD, Harrbon/Little Rock
Secretary

Dwight M. Williams, MD, Paragould
Treasurer

Anna Redman, MD, Pine Bluff
Speaker, House of Delegates

Kevin Beavers, MD, Russellville
Vice Speaker, House of Delegates

Joseph M. Beck, II, MD, Little Rock
Chairman of the Council

Established 1890. Owned and edited by the Ar-
kansas Medical Society and published under the di-
rection of the Council,

Advertising Information: Contact Stephanie
Hopkins, P.O. Box 3686, Little Rock, AR 72203;
(501) 372-2816.

Postmaster: Send address changes to: The Journal
of the Arkansas Medical Society, P. O. Box 55088,
Little Rock, Arkansas 72215-5088.

Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.

The Journal of the Arkansas Medical Society
( ISSN 0004- 1 858) is published monthly by the Arkan-
sas Medical Society, #10 Corporate Hill Drive, Suite
300, Little Rock, Arkansas 72205. Printed byTheOvid
Bell Press, Inc., Fulton, Missouri 65251. Periodicals
postage is paid at Little Rock, Arkansas, and at addi-
tional mailing offices.

Articles and advertisements published in The Jour-
n al are for the interest of its readers and do not
represent the official position or endorsement of The
Journal or the Arkansas Medical Society. The Journal
reserves the right to make the final decision on all
content and advertisements.

112 • The journal

Volume 97

WHAT WE’VE DONE FOR YOU LATELY

Paperwork Will
Decrease With New
HIPPA Regulations

By David Wroten

You probably haven’t heard much about HIPPA, hut you will.

The Health Insurance Portability and Accountability Act of 1996 is going to
have a profound impact over the next two or three years. You need to be sure
HIPPA is on your radar screen and begin now to understand its impact on your practice.

Title I, which has been in effect for the last two years, guarantees health insurance
access, portability and renewal. Title II, scheduled to be implemented during the next
two years, is aimed at simplifying and advancing e-commerce in the health care system
and guaranteeing security and privacy of health information.

Title II requires Health and Human Services to adopt national standards for electronic
administrative and financial health care transactions. There are hundreds of electronic
claim submission formats currently in use. These standards will force all health carriers,
clearinghouses and software makers to utilize one format. The costs associated with
these changes are estimated to make Y2K look like pocket change.

Providers who file electronic claims can either alter their existing systems to comply
with the standards or contract with a clearinghouse that will receive the claim as they
do now, then reformat the claim to meet the standard.

Once implemented, there will be only one electronic format for claim transactions
and other transactions that are usually handled hy paper. These include claim attachments
(i.e. progress notes, medical records, etc.), premium payments, referral and authorization
forms and claims payment and remittance advices. By mid-2002, all health carriers
must be able to accept these administrative transactions electronically.

Other provisions included in these standards require adoption of standard code sets
such as ICD-9 and CPT-4 for coding of diagnosis and services, the elimination of local
codes such as those used by Medicaid programs and unique ID numbers for individuals,
employers, health plans and providers.

The regulations for electronic transaction standards have recently been finalized.
Carriers have approximately 24 months to change their systems to comply with the
new standards, at which time they will be required to have the ability to accept all of the
mentioned transactions electronically in the standard formats. This does not affect the
ability of providers to produce and submit paper claims; they may continue to do so.

Two other provisions in Title II relate to security and privacy of medical information.
These are still in the draft or proposed mle stages but are expected to be implemented
over the next two years, as well. HIPPA mandates the establishment of security policies
by any one who maintains or transmits health information. There is a separate but
related provision dealing with privacy of medical information. Both of these provisions
will impact physicians and will require the adoption of new policies and procedures for
how medical records are handled.

The pessimist would say “here comes another round of government overregulation
that is likely to force me into early retirement.” Tire optimist would say “here is an
opportunity to go paperless and take advantage of technology to improve my bottom
line by reducing my overhead and the amount of time spent on paperwork, while at the
same time providing more assurances to my patients that their medical information is
safe and will be kept confidential.” Take your choice.

What should you do now? Realize that this is not happening overnight. Take the
time to educate yourself and your staff on what HIPPA is and is not. Numerous web sites
contain HIPPA information.The AMS and others will offer HIPPA educational programs
in the near future. Take the first step by talking with your software vendor or clearinghouse
about the transaction standards and their plan for compliance. If you have custom
software, talk to your programmer. Expect more information from the AMS as regulations
become final. ■

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Putting the Care back in Managed Healthcare

By Christy L. Smith

The Big Easy

Arkansas Physicians are Retiring Early
in the Face of More Paperwork
and Longer Work Days

Dr. Ronald Hughes, 50, retired from practice this summer to spend more time with his family, including
children, Drew, 2 1, and Lindsay, 18.

For 20 years, Dr. Ronald Hughes rarely saw daylight.

The Little Rock nephrologist found himself caught up in a
whirlwind of hospital rounds and clinic appointments that began
every weekday at 6 a.m. and did not end until 1 2 — sometimes
I 3 or 14 — hours later

Call duty every fourth night and every other weekend left even less
time for Dr Hughes to spend with his family, a straw that finally broke
this camel's back about a year ago.

"You start figuring how many hours you put into the job, and
basically at 20 years I’ve worked as many hours as most people do in 30
or 35 years," he said.

This summer the 50-year-old physician retired from private practice.
Dr Hughes now works part-time as medical director of Research
Solutions, a pharmaceuticals testing company in Little Rock, and he

“You start figuring
how many hours
you put into the job,
and basically at
20 years I’ve worked
as many hours as
most people do in
30 or 35 years.”

— Dr. Ronald Hughes

Number 4

October 2000 * 115

Avoiding Managed Care

Although it played a minor role in his
decision to change careers, Dr Hughes
acknowledged that managed care is a
problem for physicians.

“They make all the rules; they tell
you how [medicine is] going to be
practiced, and there’s an ever-increasing

Frustration with the workers' compensation system forced 48-year-old Dr. Dennis
Luter into early retirement. He is now co-owner of a drug testing company.

burden of paperwork, meetings you have to go to, hoops
you have to jump through to get things done," he said.

However Dr Hughes said he thinks physicians are
retiring early because they have so many other career
choices at their fingertips.

“There are lots and lots of opportunities out there
now for administrative positions in medicine. There are
more and more people hiring doctors. A medical degree
is a marketable commodity,” he said.

That was the case for 58-year-old Dr Jack Blackshear; a
Little Rock gastroenterologist. In 1993, after 17 years in
private practice, Dr Blackshear went to work as the
medical director of an insurance company.

“I was in the belly of the beast. I [felt] I could be an
interface between physicians and patients who had
grievances against the companies for payment,” he said.

But Dr Blackshear found himself caught between his
ethical duty to support “quality patient care” and his
employers’ denial of legitimate claims. As medical director;
he reviewed denials and overturned more than half of

serves as a quality assurance consultant to a Dallas-based
dialysis company.

“I debated for a long time trying to work out a deal
where I could keep practicing and not take call, but I'm not
sure it’s fair to your partners. It forces your partners to
work harder and ultimately places a strain on the working
relationship," Dr Hughes said.

Winding Down

Frustrated with the time commitments required by
their careers and the hassles of managed care, an
increasing number of physicians are retiring before age 60,
according to the American Medical Association.

The AMA recently conducted a telephone survey of
300 physicians in their 50s and found that 38% of them are
planning to retire in the next three years. Another 1 6% will
reduce their workloads, and 1 0% said they will stop seeing
patients in order to pursue another career

Arkansas also has been swept up by that trend, said
Lynn Zeno, the Arkansas Medical Society’s director of
governmental affairs.

“When I started with the medical
society [I I years ago], many [of the
member physicians] were just
blossoming in their mid-60s. At 65 years
old, they were still outstanding surgeons,
outstanding providers and still had a lot
of bounce in their step,” Zeno said.

But ever-increasing regulation by
insurance companies and the
government is forcing many physicians
to rethink their career paths, he said.

“They are spending far too little
time with patients and far too much
time with the administrative part, and
that’s not why they went to medical
school. Many are retiring for all the
wrong reasons," Zeno said.

And the booming economy has
given physicians the vehicle they need to
pursue other interests, he added.

“Doctors were fortunate and wise
in their investments. The stock market
has been very kind to all investors, so it’s
enabled [doctors] to build nest eggs so
they just don’t have to hassle with the
practice of medicine anymore,” he said.

116 ® The Journal

Volume 97

Photo: Kirk Jordan

them, only to have his decisions reversed later on, he said.

“Their bottom line was making a profit, and my bottom
line was geared more toward quality medicine. I was
unwilling to turn my back on my colleagues and what I knew
was really good medicine for the sake of maintaining the
viability of a company,’’ said Dr Blackshear; who determined
in 1 996 that he is “better-suited" as a physician.

Dr. Blackshear now works three days a week at John L.
McClellan Memorial Veterans Hospital in Little Rock,
performing five-six endoscopic procedures each day. In his
spare time, Dr. Blackshear plays golf, sings, practices his
clarinet, escorts medical students on mission trips and
cares for his parents. He said that managed care as well as
the idea of leading a non-scheduled life is drawing
physicians out of practice.

“When I was in medical school, we all expected to be
slaves to our calling. Young people coming into medicine
now want to be better rounded in life, [and] the
paperwork has just become overpowering. I think more
and more physicians will retire as the [managed care]
pressures grow,” he said.

Company Man

Physicians of every specialty are becoming increasingly
frustrated at losing control over the patient care process,
Zeno agreed.

“Quite frankly, the medical decision-making is not in
the hands of the doctor and patient anymore," Zeno said.

Frustration led Dr. Dennis Luterto leave his practice
last year.The 48-year-old orthopedic surgeon from
Jonesboro said he began seeking other career
opportunities five years ago because the health care
system presents far too many hurdles for physicians to
overcome.

“I loved medicine, and I loved orthopedics
particularly. But there are some things that no longer
make it tenable for many of us to keep practicing, and
managed care is only one portion of the system,” he said.

Dr Luter said he was constantly being pulled in
different directions by hospitals, insurance companies,
lawyers, patients and their employers because orthopedics
involves so many workers’ compensation cases.

“My role became not so much of a healer My role
became more of a judge, a secretary, a mediator I was
spending too much time educating insurance companies
about the nature of disease and treatment,” he said.

Dr Luter now co-owns a drug testing company, and he
spends much of his free time gardening, reading books
about art and traveling with his wife. But best of all, Dr
Luter said, he rarely experiences a sleepless night.

“That's something I hadn’t known in 20 years,” Dr.

Luter said.

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He predicts that physicians — many in their 40s — will
continue to retire as long as health care funding and
reimbursement decrease and paperwork detracts from
patient care.

“The majority of the doctors I know [in the

With an aging population, there’s a great need for that
specialty,” Zeno said.

In addition, this exodus of private practice physicians could
create a working atmosphere more to the physicians' liking, but
not necessarily geared to the patients’ needs, he said.

“We are seeing [a shortage in some specialties] right now. Statewide there is a real
shortage of pulmonologists. With an aging population, there’s a great need for that
specialty.’’ — Lynn Zeno , AMS

Jonesboro] area are looking at quitting. Most of my friends
are trying to get into something else. But what's really
disappointing is that I felt like I was at the peak of my skills
[when he retired]. I think that many others who are trying
to quit have skills, and they would be willing to work for a
whole lot less money if you could get rid of the headaches
and the hassles,” he said.

If the trend for early physician retirement continues,
then the nation may experience a shortage of specialists
and an influx of younger physicians who will impact the
business of medicine, Zeno said.

“We are seeing [a shortage in some specialties] right
now. Statewide there is a real shortage of pulmonologists.

“It’s much harder today to start a private practice
because practice costs continue to increase, yet
reimbursement from insurance carriers and government
programs continue to decrease. So, many of today’s
medical school graduates are [practicing] as employees of a
corporation — either a hospital or some other entity,”
Zeno explained.

That incorporation of medicine removes the profit
motive and encourages physicians to view themselves as 8-
to-5 employees, he said.

“There’s not quite the [profit] incentive to see 60
patients a day and to work from 6 in the morning to 6 or 7
at night," Zeno said.

Upcoming AMS Meetings

Collecting with Class and
Patient Satisfaction

Tuesday, Sept. 26

Holiday Inn Select

201 S. Shackleford, Little Rock

9 a.m. - noon

Increase Cash Flow - Decrease
Headaches

This seminar is designed for physicians
and medical office staff who want to
increase cash flow while maintaining
strong patient relations.

1:30-4:30 p.m.

Improving Patient & Professional
Relations

Quality healthcare is not the only
thing that patients consider when
choosing a physician. They want quality
service in every other respect as well.

Registration Fees:

$150 per seminar or $260 all day.
Lunch provided for participants
attending all day.

Pre-registration is required.

No refunds for cancellations received
after Sept. 15.)

AMS 2000 Fall Meeting

Embassy Suites

1 1301 Financial Centre Parkway,
Little Rock

Saturday, Oct. 28

6 p.m.

Early Bird Reception

7 p.m.

Dinner on your own

Sunday, Oct. 29

8 a.m

Tentative Committee
Meetings

9:30 a.m.

Council Meeting

All AMS Members:

11:30 a.m.

Lunch Program: Guide
to Using the Grassroots
Action Center Internet
Link

1 p.m.

Politics, Power & You
Michael E. Dunn

3 p.m.

Break

3:15 p.m.

House of Delegates
Lynn Zeno - Legislative
Agenda

CLIA/OSHA and Your
Medical Practice

Wednesday, Nov. 1

Holiday Inn Select

201 S. Shackleford, Little Rock

The Clinical Laboratory Im-
provement Ammendments of 1988
(CLIA) regulate all testing performed
to ensure quality and compliance
with the established procedures and
policies.

The Occupational Safety and
Health Administration (OSHA)
requires that all employers provide a
safe and healthful place of
employment.

Registration Fees:

$155 for members and staff and $255
for non-members.

Watch your mail for registration
materials or call the AMS office at 501 -
22^8967.

118 • The Journal

Volume 97

But the health care system is bound to correct itself,
restoring control of patient care to the physician, leveling
out the rate at which physicians are reimbursed for their
services and bestowing more accountability upon the
patient, Zeno said.

"In the late '80s, early '90s, health care costs were out
of control. In an effort to correct that, the pendulum has
swung too far in the other direction. You would hope that
at some point in time the pendulum would come back to
the middle,” he said.

Taking Control

Drs. Luter; Blackshear and Hughes agree the system will
inevitably change, but they have different ideas about the
time frame.

"I think things are going to get worse before they get
better, and I just didn't want to be in that time when
things get worse,” Dr. Luter said.

Dr. Blackshear said the changes will not come any
time soon, and they will initially take effect only in small
pockets across the nation.

"It can’t always be this way. An atmosphere of chaos
and change is where innovations come from. I strongly
believe that it's going to be a very slow process that
won’t happen nationwide, but as we see the mergers of
these managed care companies. I think [the government]
might designate a particular company to take the lead

and then give it support legislatively [to oversee a
single payer system],” he said.

In addition, patients will have to accept more
responsibility for their health care decisions, if the
changes are to be lasting, Zeno and Dr. Blackshear said.

"What’s driving the cost of health care is
overutilitization. In other words, 10 years ago if Johnny
had a sore throat, [the parent] picked up some cough
medicine or throat spray. Going to the doctor was the
last resort. Now with minimum co-payments and first
dollar coverage by insurance companies, little Johnny
goes to the doctor. With a $5 or $ 1 0 co-pay, there's no
disincentive for the patient not to overutilize health care
services," Zeno said.

Dr. Blackshear said he believes the concept of
managed care is a difficult one for patients to grasp.

"I believe in a health care system that allows patients to
spend within their means.They can’t pay $ 1 0 a month and
expect to have $ 1 ,000 in medical care as a result. Some
expectations that people have are just outlandish,” he said.

Once all these factors have come together to create
a health care system that allows physicians to concentrate
on patient care rather than paperwork, physicians who
retired early may return to practice, Zeno said.

"They all still have that desire to take care of patients.
That’s why they got into medicine in the first place,” he
said. ■

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Number 4

October 2000 • 119

Meet Our Members

Michael J. Cross, MD

By Becca Gardner

120 • The Journal

Fayetteville’s Dr. Michael Cross is a state advocate for
breast cancer awareness and research.

Volume 97

Doctors often have to answer tough questions. But
for Dr. Michael Cross everyday is often full of frightened
patients asking hard-to-answer questions.

Many are terrified when they ask, “Am I going to
die? Will I lose my breast? What is surgery like? Does
chemotherapy hurt? Will I lose my hair?”

As a surgical oncologist with his own practice in
Fayetteville, Dr. Cross often takes the extra time to reassure
patients and help them and their families come to grips
with their diagnoses. The
42-year-old doctor sees
about 250 patients
each month and
performs about 5 00

surgeries every year,
from implant removal
to breast biopsy.

A typical day at Dr.

Cross’ office could include visits from eight-nine patients
whose ages range from the early 20s to late 80s.

“My youngest cancer patient was 26 when [diagnosed],”
Dr. Cross said.

Dr. Cross often reviews slides and informs patients of
their diagnoses over the weekend so they can discuss
treatment plans as soon as possible.

“It’s me, face-to-face; it’s me answering all their
questions,” he said. “I give them a chance to ask me as
many questions as they need to ask in order to resolve what
problem they’re having. And I have a really great support
staff who make up all the appointments for [patients].”

While the staff schedules the needed X-rays, blood tests
and visits to plastic surgeons and radiation oncologists for
patients, Dr. Cross handles patients’ personal concerns.

Cutting-Edge Techniques

While Dr. Cross discusses several treatment options
with his patients, one of his specialties is performing
sentinel node biopsy.

“What we offer is breast conservation, most of the
time,” Dr. Cross said.

With sentinel node biopsy, a surgeon can identify and
remove the first draining lymph node, or sentinel node,
from the breast area. The status of the node is then used
to assess the health of the remaining nodes.

Dr. Cross has been performing the
relatively new surgery for two years and
recently co-wrote and presented a paper
on sentinel node biopsy — along with Dr.
Suzanne Klimberg, director of women’s
oncology at the Arkansas Cancer Research
Center, part of the University of Arkansas for
Medical Sciences system — for the Southwest
Surgical Congress in Colorado Springs, Colo.

Although most of Dr. Cross’ patients come from
Arkansas and surrounding states, he was visited two
months ago by a 41 -year-old Kuwaiti woman seeking
his medical expertise for her follow-up care.

Because those patients who will be rediagnosed with
cancer will be more likely to be diagnosed within two-
five years, Dr. Cross stresses the importance of follow-

up care with a physician.

“This happens so much — when
a woman comes in, her mammograms
are normal, and she still has breast
cancer,” he said. “And so 1 let them
understand: a normal mammogram
does not imply that you do not have
breast cancer.”

Funding Research

As a champion of breast cancer
awareness, Dr. Cross was reappointed
by Gov. Mike Huckabee to the
Oversight Committee on Breast
Cancer Research in January. The
committee, comprised of about 10
steady and rotating members, decides
how $4 million of state money will be
spent for breast cancer research and
treatment. Of the $4 million,
$800,000 is spent on research.

Dr. Cross said he is interested in
making sure the money goes to
“people with a national reputation for
breast cancer research, so they’ll go
on to develop bigger programs. Our

goal is for Arkansas to he a leader in
breast cancer research.”

Always the advocate, Dr. Cross
will help host Breast Cancer
Symposium 2000 and will speak to
residents of Northwest Arkansas
about new breast cancer treatments,
all in celebration of Breast Cancer
Awareness Month in October.

In addition to the governor’s
committee, Dr. Cross served on the
grants committee of the Ozark
Chapter for the Susan G. Komen
Foundation and serves on the Internal
Review Board for the Washington
Regional Medical Center in
Fayetteville. With his busy schedule,
he depends on the Arkansas Medical
Society to keep him informed about
issues affecting the practice of
medicine.

When he’s not working to
increase breast cancer awareness and
funding, Dr. Cross is an avid cyclist,
traveling 23-25 miles at a time. The
drive to stay fit partly comes from his

stint on the Arkansas Razorback
football team, where he played with
Razorback head football coach
Flouston Nutt under the coaching
arm of Frank Broyles and Lou Holtz.

After receiving his bachelor’s
degree in zoology from the University
of Arkansas in 1981, Dr. Cross
worked at the Cooper Clinic in
Dallas for a year before earning his
medical degree from the University
of Nebraska College of Medicine in

1987.

He completed a general surgery
internship and residency at Scott &
White Memorial Hospital in Temple,
Texas, in 1992 and a fellowship in
surgical oncology of the breast at
Baylor University Medical Center in
Dallas in 1993.

When he’s not kayaking or
cycling, Dr. Cross enjoys traveling and
spending time with his two daughters,
Sunni, 10, and Summer, 7. The three
recently took a camping trip to the
Grand Canyon. ■

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Number 4

October 2000 • 121

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State Senator Awarded
National AMA Award

Jay Bradford Honored for his Dedication
to Health Care Reform

By Christy L. Smith

State Sen. Jay Bradford of Pine
Bluff was one of 1 1 federal,
state and municipal gov-
ernment officials to receive a 2000
Nathan Davis Award for Out-
standing Government Service on
July 18 in Washington, D.C.

The senator said he is
“especially grateful” to U.S. Rep.

Vic Snyder and Amy Rossi,
executive director of Arkansas
Advocates for Children and
Families, for the nomination.

“Without their support, it
would not have come to pass. The
honor will bolster my courage to
keep fighting to improve the health
of my fellow Arkansans,” Sen.

Bradford said.

Presented each year by the
American Medical Association,
the award recognizes elected and
career officials whose “outstanding contributions have
promoted the art and science of medicine and the
betterment of public health,” according to the AMA. It
was named for Nathan Davis, who founded the AMA in
1847.

Sen. Bradford has represented Arkansas’ ninth
Senate district since 1983. He is president pro tern of
the state Senate and chairman of the Senate’s Public
Health, Welfare and Labor Committee. He also serves
on a dozen other committees and subcommittees.

U.S. Rep. Snyder said he nominated Sen. Bradford
for the Nathan Davis Award because the senator
demonstrates an unfailing commitment to improving the
health of Arkansas families.

“I was in the state Senate for six years. Jay was always
an advocate for public health and was always looking
for ways to improve the health of Arkansans day in and

day out. His number one issue has
always been health-related
activities. [The award] is a really nice
thing. It was a great honor for him
and he deserves it,” he said.

In his nomination letter, U.S.
Rep. Snyder noted that Sen.
Bradford has sponsored legislation
extending state health care coverage
to uninsured children and bills
seeking mental health parity,
providing individual health care
plans to students with special health
care needs and calling for research
into the health needs of those living
with HIV/AIDS.

In addition to advocating a
breast cancer research program
funded by taxes on tobacco products,
Sen. Bradford has assumed a “major
role in the debate on the tobacco
settlement, maintaining the view
that these funds should be dedicated to treating smoking-
related diseases and conducting smoking prevention
programs,” U.S. Rep. Snyder wrote.

Katherine Waite, the AMA’s government affairs
assistant, said 31 other state senators were nominated
for the Nathan Davis Award this year. The awards also
annually recognize a U.S. representative; members of
the federal executive branch serving by political
appointment, in career public service and in career
military service; a governor; a state representative; a
member of a city or county government; and a career
public servant at the local level.

“Through these awards, the AMA strives to
encourage and stimulate recognition for the highest
public service standards throughout all levels of
government,” said Robert J. Mills, the AMA’s public
information officer. ■

Sen. Jay Bradford

Number 4

October 2000 • 1 23

LOSS PREVENTION

Hallmarks of Patient Care:
History, Examination, Suspicion

J. Kelley Avery, MD

The

diagnosis in
this case was
acute

epididymitis,
which is the
usual
diagnosis
confused
with torsion.
The onset is
usually not
sudden, with
symptoms
beginning a
few days
before the
patient goes
to the
physician.

A 24-year-old obese man reported to a minor
medical center after the sudden onset of pain in
the right testicle for one hour. The patient’s
temperature was 99°F, pulse 86/min, and his blood
pressure was normal. He weighed 325 pounds and
was 6-feet, 1-inch tall. Documentation of the
physical examination was confined to the genitalia,
noting only “swollen right testicle/epididymis with
tenderness locally. Inguinal canal OK.”

The diagnosis was recorded as epididymitis,
right. The patient was given an antibiotic by
injection and a prescription for the same to be
taken by mouth. The instructions given by the
physician, though not documented, were said by
the patient to be, “Report to the hospital
emergency department if pain does not subside.”

Four hours later, six hours after onset of pain,
the patient reported to the medical center hospital
emergency department with the same severe pain
in the right testicle. The examination on this
occasion revealed a swollen, tender right testicle
and epididymis. The remainder of a complete
physical examination was within normal limits
except for obesity. The history revealed therapy
with Dilantin for a seizure disorder. He had not had
a seizure for a year, though he took the antiseizure
medication irregularly. Urinalysis revealed some
protein, and his WBC count was 12,000/cu mm
with 89% segmented neutrophils. The admission
diagnosis was acute torsion, right testicle.

Operation disclosed a dark blue right testicle,
with the cord showing a 540 degree torsion. The
torsion was reversed, and exploration of the left
testicle showed it to be normal; sutures were placed
to fix it in the normal position. The infarcted right
testicle was removed, and pathology reported the
testicle was indeed dead. The postoperative course
was normal, and recovery was complete.

A lawsuit was filed by the patient charging the
physician in the minor medical facility with
negligence in failure to diagnose the torsion of the
testicle resulting in the loss of the testicle and the
possibility of infertility. Expert review indicated the
physician did not provide treatment to his patient
that would meet the prevailing standard of care.

Loss Prevention Comments

The marked obesity of this patient possibly
complicated the physical examination and the

diagnosis, but the history in this case was typical
of testicular torsion. The onset was sudden,
without any predisposing factors. If seen in the
first hour the finding is usually tenderness in the
testicle with some swelling. The tenderness is
significant, and sometimes the testicle is slightly
to moderately swollen. The testicle may lie
higher than normal in the scrotum, and careful
palpation may occasionally reveal the torsion.
The urinalysis may be totally negative. Survival
of the testicle is extremely rare after four hours
of torsion, so prompt diagnosis and treatment is
imperative.

The diagnosis in this case was acute
epididymitis, which is the usual diagnosis
confused with torsion. The onset is usually not
sudden, with symptoms beginning a few days
before the patient goes to the physician.
Examination more often reveals a tender, swollen
testicle that may show some redness, induration
and warmth of the skin. The laboratory should
show more evidence of infection, with more fever
and elevation of the WBC count.

The use of imaging technology has been
studied, and as yet the specificity of diagnosing
acute torsion of the testicle is not encouraging.
One fact that may increase the value of a case
like this is that about 25% of these patients are
infertile afterwards, likely due to some ischemia
of the other testicle triggered by the insult of
torsion.

Because of the opinion of the specialists who
studied this case, and the unanimous opinion that
the physician was outside the standard of care, a
modest settlement was negotiated. The hallmarks
of this diagnosis appear to be a good history, a
good examination and a high index of suspicion
for the condition. None of these seemed to be
present here, or if they were, they did not appear
in the medical record. ■

The case of the month is taken from actual
Tennessee closed claims. An attempt is made to
fictionalize the material in order to make it less easy
to identify. Dr. A very is a member of the Loss
Prevention Committee, State Volunteer Mutual
Insurance Co., Brentwood, Tenn. This article
appeared in the May 2000 issue of Tennessee
Medicine. It is reprinted with permission.

124 • The Journal

Volume 97

CT Scans are Helpful
in Acute Abdomen Cases

EDITOR AND AUTHOR: Steven Nokes, MD — AUTHOR: Josue Montanez, MD

History

A 50-year-old man presented to the emergency
department with right lower quadrant pain. Plain
films were unremarkable and a CT scan was
performed (Figures 1-3).

Findings

Figure 1 reveals a poorly defined target sign
within the cecum consisting of alternating layers of
bowel and fluid. In the center of the image is a
reniform mass with mesenteric fat and vessel
intussuscepting into small bowel. Figure 2 shows a
2-centimeter low-density lipoma within the right
lower quadrant. This was the lead point. This is well
defined on the coronal reconstruction (Figure 3).

Diagnosis: Ileocolic intussusception

Figure 2. CT scan of the abdomen.

Figure 1. CT scan of the abdomen.

Figure 3. Coronal reconstruction of the helical data.

Number 4

October 2000 • 125

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Discussion

CT has become an integral part of
the work up of the acute abdomen. It is
particularly helpful in the work up of
appendicitis, diverticulitis and small
bowel obstruction (SBO), where the
accuracy of CT is 95-100%.

The most common cause of SBO is
an adhesion secondary to prior surgery.
Hernias are the second leading cause.
Less common causes include tumors,
intussusception and closed loop
obstruction. CT allows a specific
preoperative diagnosis of intus-
susception. Early cases demonstrate a
doughnut sign due to mesenteric fat
extending into the bowel wall. Later a
target sign is encountered with
alternating layers of differing
attenuation reflecting closely applied
bowel wall, mesenteric fat, mesenteric
vessel, intestinal fluid, gas and
sometimes contrast. This is analogous
to the “coiled spring” appearance seen
on barium studies. A reniform mass
suggests associated bowel ischemia (as
in this case). Fifty percent of colonic
intussusceptions in adults are secondary
to malignant neoplasms. Lipomas of the
ileocecal valve are the second most
common cause. In our case, a
submucosal ileal lipoma was the leading
edge, confirmed at surgery. Several feet
of gangrenous ileum were removed. ■

References:

1. Urban BA, Fishman EK. Targeted
helical CT of the acute abdomen.
Appendicitis, diverticulitis and
small bowel obstruction. Sem in
US, CT and MRI 2000; 21:20-39.

2. Parienty RA. Lepreux JF. Gruson
B. Sonographic and CT features of
ileocolic intussusception. AJR
1981-7 136: 608-610.

3. Merine D. Fishman EK Jones B.
Siegelman SS. Enteroenteric
intussusception: CT findings in
nine patients. AJR 1987; 148:
1129-1132.

Drs. Nokes and Montanez are with
Radiology Consultants of Little Rock.

126 • The Journal

Volume 97

UPCOMING EVENTS

Arkansas
Country Doctor
Museum

September 29 ■ October 1

Lincoln’s Annual
ipple Festival will be
eld. The Arkansas
Country Doctor Mu-
seum, just one block
from the Town Square at 107 N.
Starr Ave., will host a gala open
house from 10 a.m.-5 p.m. Sept. 29.
The open house will continue from
10 a.m.-5 p.m. Sept. 30 and Oct. 1.
A special exhibit of wood-carvings
hy local artist Barbara Griscom also
will be on display. Folk music by
Fireside Friends will begin at 1 p.m.
Sept. 30.

October 7

Phillip Steele, au-
thor of “The Family
Story of Bonnie and
Clyde,” will talk about
his latest book at 2 p.m.
at the museum.

October 17

The Country Roots
Genealogy Society will
meet at 6:30 p.m. at the
museum.

The Arkansas Country Doctor
Museum, located in Lincoln, is
currently developing a docent
program and is raising funds for the
Hall of Honor project, which will
honor Arkansas’ country doctors,
past and present. ■

For more information on the
museum or to donate, call (501 ) 824-
4307, e-mail acdm@pgtc.net or visit
www.drmuseum.net.

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Number 4

October 2000 • 127

CARDIOLOGY

Anticoagulation Management in
Mechanical Heart Valve Patients
Who Undergo Dental Procedures

Jill T. Johnson, Pharm.D. — Mark C. Granberry, Pharm.D. — Audra R. Thomas, Pharm.D.

EDITOR: Eugene S. Smith, MD

This month’s case discusses a rather
common problem faced in patients
receiving anticoagulation . Often primary
care specialists or cardiologists must make
recommendations regarding warfarin
therapy before and after dental procedures .
This review seeks to help practitioners
balance between over and under
anticoagulating these patients during the
peri-procedural period.

Patient Presentation

History: A 66-year-old female
requiring anticoagulation with warfarin
s/p aortic valve replacement with a St.
Jude valve was planning to undergo
dental surgery. She was known to have
had a coronary artery bypass graft, a
gastrointestinal (GI) bleed in the past,
and decreased left ventricular function
with an ejection fraction of 25-30%.
Her target international normalized
ratio (INR) was 2. 0-2. 5 due to her
history of GI bleeding. Her home
medications included warfarin 6 mg
daily for six days per week with 4 mg
on Mondays, valsartan 80 mg every day,
amlodipine 10 mg every day and
calcium 600 mg twice daily. She was
not taking aspirin secondary to her GI
bleeding history.

Four weeks prior to her dental

procedure her INR was 1.9. Two days
prior to her dental procedure she was
instructed to skip her warfarin doses
and to restart her current warfarin
regimen when she returned home
after the procedure. She underwent
decalcification of six teeth in which
her gums were cut and the teeth were
rebuilt. Two days after her procedure,
her INR was 1 .6. One month after her
procedure, no thrombotic event had
been reported. Her INR at that time
was 2.5.

Discussion

Long-term anticoagulation with
warfarin is the standard of care to

prevent thromboembolism for patients
with mechanical prosthetic heart
valves. When these patients require
oral surgery procedures, questions
frequently arise on how to best manage
their anticoagulation. Due to the
perceived likelihood of significant
bleeding, anticoagulation is often
interrupted during the days
surrounding the procedure. However,
even short-term discontinuation of
anticoagulation may place the patient
at significant risk for thromboem-
bolism. Therefore, before anti-
coagulation is interrupted, the
potential of significant bleeding must
he weighed against the increased

Table 1.

Summary of ACC/AHA recommendations for management of
anticoagulation in patients with mechanical heart valve replacements
planning to undergo dental surgery.

All types of mechanical heart valves
Discontinue aspirin 7 days before procedure
Low thromboembolic risk

Stop warfarin 2-3 days before procedure; allow INR to fall to 1 .5. Restart
warfarin within 24 hours of procedure.

High thromboembolic risk

Stop warfarin. Administer heparin when INR falls below 2.0. Stop heparin
4- 6 hours before procedure. Restart warfarin within 24 hours of procedure.

128 • The Journal

Volume 97

Table 2.

Factors that place a patient at a high thromboembolic risk.
Risk Factors

♦ Thromboembolism during the previous 1 year

♦ Bjork-Shiley valve in any position

♦ Previous thromboembolism when off warfarin

♦ Any of 3 of the following:

>- Mechanical heart valve in the mitral position
>- Atrial fibrillation
»- Ejection fraction <30%

Hypercoagulable condition
>- Previous thromboembolism

thromboembolic risk.

The rate for throm-
boembolism associ-
ated with mechanical
heart valves without
anticoagulation varies
from 3-13% per year
and is dependent on
type and placement of
prosthesis. Aortic
placement of a me-
chanical valve carries
the lowest risk for
thrombosis with mi-
tral placement and the
combination of aortic with mitral
placement having relatively higher
thromboembolic risks.1,2 In addition,
tilting disc valves and bileaflet valves
have a lower embolic risk than caged
ball valves. Without anticoagulation,
the risk for major embolism is four
events per 100 patient-years while the
risk for valve thrombosis is 1.7 events
per 100 patient years. With sufficient
anticoagulation, these risks are reduced
by 75% per year. The risk for
thromboembolism is greater the longer
anticoagulation is held and is
estimated to be 0.016% for one day of
interruption. For example, if anti-
coagulation was withheld for four days
surrounding a dental surgery
procedure, the risk of any throm-
boembolic event would be 4(4 +
1.7)/365=0.062%, or 6.2 in 10,000,
compared to only 3.1 in 10,000 if the
anticoagulant was held for only two
days.2 If a thrombus forms, it likely
forms slowly over as long as two

months. Therefore, absence of a
thrombotic event occurring early after
interruption of anticoagulation may
give the clinician a false sense that the
patient has not suffered or will not
suffer any thrombotic consequence.
Some practitioners hospitalize patients
to discontinue warfarin and initiate
heparin to minimize the time the
patient spends without anti-
coagulation. Others allow the patient
to stop warfarin without any other
means of anticoagulation because they
believe the thrombotic risk to the
patient is negligible.3

The incidence of bleeding is 1.4
per 100 patient-years with oral anti-
coagulation therapy alone and 4.6 per
100 patient-years when an antiplatelet
is added.2

Dental procedures such as routine
teeth cleanings, fillings and crowns
have not been shown to increase the
risk for bleeding in anticoagulated
patients.4 Therefore, it is reasonable

to continue full anticoagula-
tion in patients undergoing
these procedures.

The American College
of Cardiology and the
American Heart Associ-
ation currently recommend
the management of anti-
coagulation in patients
with mechanical heart
valve replacements plan-
ning to undergo dental sur-
gery be individualized. The
risk of bleeding during the
procedure should be
considered; dental cleaning and
treatment of dental caries should be
completed without discontinuing
anticoagulation. (Table 1) If the
patient is taking aspirin, it should be
dis-continued seven days before the
procedure and be restarted the day after
the procedure or after active bleeding
ceases. The ACC/AHA also reco-
mmend that warfarin be stopped two-
three days before a dental procedure
to allow the INR to drop to 1.5 or
below and to restart warfarin within
24 hours of the procedure. For patients
at high risk for thromboembolism,
heparin should be started once the INR
falls below 2.0 and stopped four-six
hours before the procedure. (Table 2)
High risk is defined as having a
thromboembolism within the previous
year, a Bjork-Shiley valve in any
position or having previously suffered
thromboembolism when off warfarin
therapy. If a patient has three or more
risk factors including any type of

Table 3.

Trials of tranexamic acid rr

Study

louthwash (TAM) in rru

Type of procedure

?chanical heart valve patients undergc

Comments

)ing dental surgery.

Conclusion

Souto, et al.6

Tooth extractions

Anticoagulant dose was
decreased for 2 days

Bleeding was significantly
reduced by TAM

Sindet-Pedersen, et al.7

Oral surgery

Placebo-controlled, double-blind,
randomized; anticoagulant doses
were not decreased

Statistically fewer bleeding
episodes with TAM

Borea, et al.s

Single dental
extraction

TAM without altering the
anticoagulant dose vs. placebo

No difference between the
2 groups

Ramstrom, et al.9

Oral surgery

while discontinuing mouthwash

TAM vs. placebo; neither group
discontinued anticoagulant

The placebo mouthwash
group experienced
more bleeding

Number 4

October 2000 • 1 29

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fibrillation, LV dysfunction (EF<30%),
a hypercoagulable condition and
previous thromboem'bolism, heparin
should also be instituted. Heparin
should also be initiated in a patient
with any mechanical heart valve type
in the mitral position if any additional
risk factor exists.5

An alternate strategy to minimize
both the risks of bleeding due to dental
surgery and thromboembolism due to
interruption of anticoagulation is to
maintain systemic anticoagulation
while creating a localized area of near
normal coagulation around the
surgical site. Tranexamic acid has been
evaluated in a mouthwash form as a
local antifibrinolytic agent.

Three studies evaluating the use
of tranexamic acid mouthwash in
mechanical heart valve patients
undergoing extractions or oral surgery
demonstrated that patients receiving
the antifibrinolytic mouthwash
experienced fewer bleeding episodes
than the control groups. Another
study found there to be no difference
between those who received mouth-
wash without altering the anticoagu-
lant dose versus placebo mouthwash
while discontinuing the anticoagu-
lant. (Table 3)

Conclusion

The management of anticoa-
gulation in mechanical heart valve
replacement patients undergoing
dental procedures must be indi-
vidualized. Consideration must be
given to the type and position of the
valve, the patient’s previous throm-
botic history when left unanti-
coagulated and other risk factors for
thrombosis. The risk of procedure
related bleeding for anticoagulated
patients must be weighed against the
potential for thrombotic consequences
in patients whose anticoagulation is
interrupted. Tranexamic mouthwash
is one alternative for reducing the risk
for local bleeding during and after oral
surgery without interrupting systemic
anticoagulation. ■

References

1 . Kontos GJ, Schaff HV. Thrombotic
Occlusion of a prosthetic heart

1 30 • The Journal

Volume 97

valve: diagnosis and management.
Mayo Clin Proc. 1 985;60: 1 18-22.

2. Cannegieter SC, Circulation
1994;89:635-41.

3. Tiede DJ, et al. Management of
Prosthetic Valve Anticoagulation.
Mayo Clin Proc. 1998;73:665-80.

4- Benoliel R, Leviner E, Katz J, et al.
Dental treatment for the patient on
anticoagulant therapy:
Prothrombin time value-what
difference does it make? Oral Surg
Oral Med Oral Pathol.
1986;62:149-151.

5. Bonow RO, Carabello B, de Leon
Jr AC, et al. ACC/AHA guidelines
for the management of patients
with valvular heart disease: A
report of the American College of
Cardiology/American Heart
Association (Committee on
management of patients with
valvular heart disease). J Am Coll
Card. 1998;32(5): 1486-1582.

6. Souto JC, Oliver A, Zuazu-Jausoro
IZ, et al. Oral Surgery in
Anticoagulated Patients without
reducing the dose of oral
anticoagulant: A prospective
randomized study. J Oral
Maxillofac Surg. 1996;54:27-32.

7. Sindet-Pedersen S, Ramstrom G,
Bernvii S, et al. Hemostatic effect
of tranexamic acid mouthwash in
anticoagulant-treated patients
undergoing oral surgery. N Engl J
Med. 1989;320:840-3.)

8. Borea G, Montebugnoli L, Capuzzi
P, et al. Tranexamic acid as a
mouthwash in anticoagulant-
treated patients undergoing oral
surgery. Oral Surg Oral Med Oral
Pathol. 1993;75:29-31.

9. Ramstrom G, Sindet-Pedersen S,
Hall G, et al. Prevention of
postsurgical bleeding in oral surgery
using tranexamic acid without dose
modification of oral anticoagulants.
J Oral Maxillofac Surg.
1993;51:1211-16.

Drs. Johnson, Granberry and

Thomas are with the College of

Pharmacy, University of Arkansas for

Medical Sciences in Little Rock. Dr.

Smith is with the College of Medicine ,
DAMS.

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Number 4

October 2000 • 1 31

SCIENTIFIC ARTICLE

The Reality of Mammography
Utilization in the State of Arkansas

Abdul Rahman Jazieh, MD MPH — Indu Soora, MPH, CHES — Harry Mohrmann, MS

0-9 = 11
Counties

>9-19 = 27
Counties

>19-29 = 28
Counties

>29-39 = 8
Counties

>39-49 = 1
County

Figure 1 : Mammography rates in each county for women 40 years and older.

The Arkansas Mammography Data
Collection Project, funded by the Arkansas
Department of Health, aimed to determine
the mammography screening patterns
throughout the state of Arkansas. Data
were obtained from 92 mammography
centers out of 1 12 centers (82%) .

A total of 157,976 mammography
data sets were obtained for 148,586
women. Mammography rate was 22.7%
for women 40 years and older and 24-1 %
for women 50 years and older.
Mammography rates per county varied
from 0.3% to 42.6%. The overall low rate
of mammography utilization reflects the
need to intensify public health interventions
and continuous evaluations of these
interventions .

Introduction

Breast cancer is the second leading
cause of cancer death in women in the
United States. It is estimated that
1 76,300 new cases of breast cancer with
43,700 related deaths occurred in 1999.'
In Arkansas, 381 women died from
breast cancer in 1998. 2

Early detection provides survival
advantage and better chance of cure for
women with breast cancer. Since
mammography is currently the best
mass screening tool available, it is
imperative that women over age 40
undergo screening mammography
routinely.3'7

In Arkansas, 49% of the population
resides in rural areas with 16% of the
population being African-American.
Furthermore, African-Americans
constitute about 50% of the population
of the Delta region. These facts present
a challenge in terms of public health
planning and interventions. Therefore,
BreastCare of the Arkansas Department
of Health funded several interventions

that promote early detection, diagnosis
and treatment of breast cancer in
Arkansas.

Arkansas Mammography
Data Collection Project
(MDCP)

The MDCP was funded by
BreastCare to compile and analyze the
mammography data for the state of
Arkansas during 1997. The purpose of
the project was to determine the
mammography rates and describe
screening practice patterns at the state
and county levels.

All 112 FDA approved mamm-
ography centers were contacted and

requested to participate in the project.
Data elements inquired from the
participating centers were: date of
birth, race (Caucasian, African-
American, other, unknown), ethnicity
(Hispanic or non-Hispanic), insurance
status (private, Medicare, Medicaid,
none, unknown), date of mammogram,
type of mammogram (screening,
diagnostic or unknown) and zip code
of residence. The data was entered into
the specifically designed Access™
database. Analysis was performed to
determine the pattern of mam-
mography utilizatiort by age, race,
mammography type and insurance
status. The mammography rate and the

1 32 • The Journal

Volume 97

mammography rate by race were
calculated using the MDCP database
and the 1997 estimated census data.

Results

Out of 1 12 mammography centers,
92 centers participated in the project
(82%) The estimated total number of
mammograms performed was 202,606.
The MDCP collected 157,976
mammography data sets from the
participating centers due to
nonparticipation of 20 centers. The
total number of individual women
imaged was 148,586 and 90% of them
were women ages > 40 years
(N = 133,549). The analysis was per-
formed mainly on the latter group of
women.

Only 22.7% of women ages > 40
years had mammograms. The rate was
slightly higher for women ages > 50 year
(24-1 %)• Age was unknown for only
3% of the women imaged (Table 1).
The mammography rates by each
county are depicted in Figure 1 and it
ranges from 0.3% (Miller County) to
42.6% (Cleburne County).

The screening mammograms were
most prevalent (61.2%) followed hy
diagnostic mamm-ograms (34-7%),
with only 4% of the mammography type
unknown (Table 2). The race in-
formation was available for approx-
imately 50% of the women
imaged. Determining the
mammography rates by race
showed a lower rate for
African-Americans as com-
pared to Caucasians and other
categories (7.8%, 11.4%, and
1 1%, respectively).

Private insurance was the
most common type of
insurance among these women
(46.9%), followed by Medicare
(18.4%) and both (5%). Only 1.6% had
Medicaid and 6% were uninsured.
Insurance status was not known in
22.3% of women.

Discussion

In spite of the large number of
mammography centers, the retro-
spective nature of the project, and many
barriers encountered, the MDCP staff

were able to secure the participation of
82% (N=92) of the mammography
centers in Arkansas. This fact reflects
the support and collaboration of the
health care organizations in Arkansas
to such public health projects. On the
other hand, the mammography rate is
noticeably low since less than 25% of
the women 40 and older obtained
mammograms in 1997. Even if adjusted
for missing data, less than one third of

Table 1 .

Mammography Rates by Age
in the Participating Centers
Using 1 997 Estimated

Census Data.

Age Groups

Rate

30-39

4.9%

40-49

19.4%

40-above

22.7%

50 and above

24.1 %

the women obtained mammograms.
The mammography rates are
remarkably variable, with 1 1 counties
having mammography rates in single
digits. Only one county has a
mammography rate more than 40%.
These results should alarm the health
care providers and public health pro-
fessionals to intensify their efforts to

increase the number of women having
mammograms through various public
and professional educational interven-
tions.

It is intriguing to notice that the
monthly mammography rates were
fairly consistent between 10,000 and
14,000 mammograms per month,
except for October, in which 16,311
mammograms were performed. This

may be attributed to the fact that
October is Breast Cancer Awareness
Month.

This MDCP baseline data will assist
in evaluating the effectiveness of
public health interventions. There-
fore, a similar project should be
conducted in the future to determine
trends in the mammography rates in
Arkansas. These results also
identified certain geographical
regions in the state with very low
rates. Further evaluation of these
areas is needed to better understand
the reasons and the best way to
remedy this problem. Establishing
statewide tumor registry would be of
great value to accomplish all these
results and it will complement the
efforts of other states that already
established such activity with the
support of the National Cancer Institute
Breast Cancer Consortium.8'11

Conclusion and Future
Direction

The majority of the women in
Arkansas did not have mammograms
in 1997. Health care providers and
public health professionals should
enhance their efforts to increase the
number of women obtaining mam-
mograms.

The MDCP is the first project ever
to compile mammography data
in a systematic and comp-
rehensive manner in the state of
Arkansas. Similar future projects
or even establishing statewide
mammography registry are
warranted to determine
mammography trends and to
evaluate the efficacy of the
ongoing public health interven-
tions.

For more detailed infor-
mation, visit the web site at
www. acre . uams . edu/ mdcp .

Acknowledgments

The authors are indebted to
Rebecca Morris-Chatta, MPH, for all
her help throughout the project. The
project was supported by a grant
awarded hy the Arkansas Department
of Health. ■

Table 2.

Mammography Rates by Exam Type in the MDCP
Database for Women 40 and Older.

Type of Mammogram MDCP

Percentage

Data

Screening

81,649

61 .2%

Diagnostic

46,386

34.7%

Unknown

5, 514

4.1%

Total

133,549

100%

Number 4

October 2000 • 133

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References

1 . Landis SH, Murray J, Bolden S, and
Wingo PA. Cancer Statistics, 1999.
CA: A Cancer Journal for Clinicians

1999;49(1):8-31

2. Greg Potts. Breast Cancer Screening
Increasing. Arkansas Health Counts
1999;5(2);l-3.

3. Shapiro S, Venet W, Strax P, Venet L.
Periodic screening for breast cancer:
the Health Insurance Plan Project and
its sequelae, 1963-1986. Baltimore:
Johns Hopkins University Press, 1988.

4. Tabar L, Fagerberg G, Duffy SW, Day
NE. The Swedish two county trial of
mammographic screening for breast
cancer: recent results and calculation
of benefit. J Epidemiol Community
Health 1989; 43:107-114.

5 . Eddy DM. Screening for breast cancer.
Ann Int Med 1989; 111:389-399.

6. Kerlikowske K, Grady D, Rubin SM,
et a]. Efficacy of screening mammo-
graphy: a metaanalysis. JAMA 1995;
273:149-154.

7. Smart AR, Hendrick E, Rutledge III
JH, Smith RA. Benefit of mammo-
graphy screening in women ages 40-49
years: current evidence from random-
ized controlled trials. Cancer 1995;
75:1619-1626.

8. Carney PA, Poplack SP, Wells WA,
Littenberg B. The New Hampshire
Mammography Network: Develop-
ment and design of a population -
based registry. AJR 1996;167:367372.

9. Yankaskas BC, J ones MB, Aldrich TE.
The Carolina Mammography Registry.
A populationbased mammography
and cancer surveillance project. J Reg-
istry Management 1996; 23:175-178.

10. Geller BM, Worden JK, Ashley JA,
Oppenheimer RG, Weaver DL.
Multipurpose Statewide Breast Cancer
Surveillance System: The Vermont
Experience. J Registry Management
1996; 23:168-174.

1 1 . Ballard-Barbash R, Taplin SH,
Yankaskas B, Emster VL, Rosenberg
RD, Carney PA, Barlow WE, Geller
BM, Kerlikowske K, Edwards BE,
Lynch CG, Urban N, Chervala CA,
Key CR, Poplack SP, Worden JK, and
Kessler LG. Breast Cancer Surveil-
lance Consortium: A national mam-
mography screening and outcomes
database. AJR 1997;169:1001-1008

Drs . Jazieh, Socrra and M ohrmann are urith the

University of Arkansas for Medical Sciences .

Little Rock 501-224-8884 • Pine Bluff 870-534-4532 • Searcy 501-268-3528

Arkansas Medical Society’s

Physician’s Legal Guide

Be one of the first to obtain this guide which contains a
miltitude of state and federal laws
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This guide is a valuable resource for
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1 34 « The Journal

Volume 97

PEOPLE+EVENTS

Dr. Thomas A. F ormby of Searcy receives the 2000 Distinguished Alumnus Award from his classmate ,
Dr. Junius Cross.

HONORED

Searcy Physician
Named Distinguished
Alumni

Dr. Thomas A. Form-

by, a family practitioner in
Searcy, received the Dis-
tinguished Alumnus Award
for 2000 by the College of
Medicine at the University
of Arkansas for Medical
Sciences.

Dr. Formby earned his
medical degree from UAMS
in 1950. He was one of the
first World War II veterans
to enter UAMS’ medical
school on the GI Bill. Dr.
Formby continued his
training at City Receiving
Hospital in Detroit and
returned to Arkansas as a
small town family physician.

He also was instrumen-
tal in opening a commun-
ity-based hospital, White
County Medical Center,
which has been thriving
while similar hospitals have
closed.

Jacksonville Doctor’s
Life Honored

A fund-raiser was re-
cently held in Jacksonville
for an endowment that will
help family practitioners
finish their residencies at the
University of Arkansas for
Medical Sciences. The
endowment is named after
Dr. James R. Weber, a
Jacksonville family prac-
titioner who practiced medi-
cine for more than 30 years
before dying in November
1998 of brain cancer.

Dr. Weber also taught

for more than 25 years at
UAMS’ department of
family and community
medicine. In recognition of
his many contributions to
medicine and medical
education, UAMS created
the James R. Weber En-
dowment in Family Med-
icine Residency Education.
The endowment has raised
$100,000 in pledges; the
goal is to raise $500,000.

Part of the income of the
endowment will help to pay
the salary of Dr. Weber’s
wife, Cynthia Weber, who
teaches UAMS family
practice residents how to
manage a medical practice
and is serving as this year’s
Arkansas Medical Society
Alliance president.

Among those in atten-
dance were Dr. Charles H.
“Shot” Rodgers, Dr. Alan
Storeygard, Dr. Dan Knight,

U.S. Rep Vic Snyder and Dr.
I. Dodd Wilson.

AMA Names
PRA Recipients

Each month the Amer-
ican Medical Association
presents the Physician’s
Recognition Award to those
who have completed accep-
table programs of contin-
uing education.

AMA recipients for May
include Drs. Devon R.
Ballard, Robert J. Belk,
Kimberly L. Cadle, Chris-
topher J. Danner, Robert D.
Dickins, Laura L. Eckles,
James P. Florez, Kamil I.
Hanna, Stephen A. Hath-
cock, Christina A. Jetton,
David C. Kolb, Chris A.
Meeker, John M. Mhoon,
Steven R. Nokes, Paul H.
Pappas, Lila P. Pappas,
Grzegorz A. Pitas, Lucas O.
Platt and Britton C. Wells

of Little Rock; William L.
Diacon of Rogers; Ivy V.
McGee-Reed of North
Little Rock; Drs. Elizabeth
B. Nelson, Christopher
Van Asche and John S.
Stockburger of Fort Smith;
William S. Stubblefield of
Brookland, Ark.; and Jon A.
Tarpley of Texarkana, Ark.

Fort Smith Doctor
Broadcasts from Italy

Dr. Lonnie E. Harrison,

a vascular and cardiac
interventionalist physician
from Fort Smith, parti-
cipated May 17 in the
“Vascular Interventions
2000” international con-
ference in Milan, Italy.

In a live case broadcast,
Dr. Harrison and an Italian
colleague demonstrated the
technique and safety of
cutting balloon angioplasty
for correcting heart disease.

Number 4

October 2000 • 1 35

Dr. Lonnie Hanison of Fort Smith, second from left, participates in a live case broadcast in Milan, Italy.

Dr. Harrison is regarded
as one of the world’s experts
on the procedure and is a
proctor for cutting balloon
angioplasty for the United
States. He currently is
proctoring the Arkansas
Heart Hospital in Little
Rock and is chief of
cardiology at the Oshner
Clinic in New Orleans,
University of Alabama and
several other major cardiac
programs in the country.

Dr. Harrison also was an
investigator in the FDA
Cutting Balloon Angio-
plasty registry, and all his
cases now have been
audited. He presented the
FDA with a 0% mortality
and 0% major adverse
cardiac event statistics. In
Arkansas, cutting balloon
angioplasty is only avail-
able at Sparks Regional
Medical Center in Fort
Smith.

EVENTS

Cancer Summit
To Fight Disease

The first-ever Arkansas
Cancer Summit for health
care professionals will be
held from 8 a.m.-6 p.m.
Sept. 28 at the North Little
Rock Hilton Inn, 2 River-
front Place.

The summit, sponsored
by the Arkansas Depart-
ment of Health, American
Cancer Society, Centers for
Disease Control and Pre-
vention and the Breast and
Cervical Cancer Control
Program, will include ses-
sions on policy and legis-
lative successes in cancer
control planning, Arkan-
sas’ current state of health
affairs, state-of-the-art
techniques for cancer
screening and treatments
and the Arkansas Central
Cancer Registry.

1 36 ® The Journal

Arkansas ranks 16th in
cancer mortality rates among
the 50 states. Although
many other states have
developed collaborative
plans to fight cancer, Arkan-

sas has yet to do this. The
Arkansas Cancer Summit
will help decrease dupli-
cation in cancer services and
develop better ways to con-
trol the disease.

Actor and cancer sur-
vivor Ann J tllian will be the
keynote speaker. Regis-
tration fee is $50. Call the
American Cancer Society at
603-5200. ■

Resolution

Aubrey M. Worrell Jr., MD

WHEREAS, the members
of the Jefferson County
Medical Society are deeply
saddened by the death of an
esteemed member, Aubrey M.
Worrell Jr., MD; and

WHEREAS, Dr. Worrell’s
dedication to his profession was
evidenced by many years of
membership in this Society, the
Jefferson County Medical
Society, the Arkansas Pediatric
Society, the American Aca-
demy of Pediatrics and the
International Academy of Nu-
trition and Preventive Med-
icine, and as a valued member
of the medical staff at Jefferson
Regional Medical Center, and

WHEREAS, Dr. Worrell
served his country and his
fellow man as a Air Force
medical officer in the United
States Air Force from 1963-
1973, retiring as a lieutenant

colonel, and

WHEREAS, Dr. Worrell
continually expanded and
enhanced his medical practice,
beginning as an .allergist-
immunologist in 1973 and moving
into the fields of environmental
medicine in 1980 and nutritional
biochemistry in 1984, and

WHEREAS, Dr. Worrell
demonstrated his leadership
abilities as past-president of the
American Academy of Environ-
mental Medicine, and

WHEREAS, Dr. Worrell was
recognized for outstanding
excellence in teaching within the
field of Environmental Medicine
by receiving the Herbert J. Rinkel
Award, and

WHEREAS, Dr. Worrell
shared his expertise with other
health care professionals by
serving on the board of trustees of
Baptist Memorial Health Care
System Inc. at Memphis, and
WHEREAS, Dr. Worrell

inspired thousands of medical
students as an assistant clinical
professor of pediatrics for the
University of Arkansas College
of Medicine at Little Rock; and
WHEREAS, Dr. Worrell
inspired thousands of
individuals in his own
community as a public servant,
presiding as a deacon and
Sunday school teacher and
playing an instrumental role in
the development of a television
ministry in Pine Bluff, and
BE IT THEREFORE RE-
SOLVED:

THAT, this resolution be
adopted and placed in the
archives of the Society; and
THAT, a copy be sent to
Dr. Worrell’s family as an
expression of our sincere
sorrow; and

THAT, a copy be made
available to The Journal of the
Arkansas Medical Society for
publication.

Volume 97

ARKANSAS RETREATS

Blanchard Springs Caverns

For vacationers seeking seclusion, the Ozark Mountain
region is a mecca that offers a bounty of intriguing outdoor
attractions, such as Blanchard Springs Caverns.

For the first time, the National Forest System, which
operates the park, will offer guided hikes into undeveloped
sections of the caverns as part of its Wild Cave Tour. On
the tour, visitors will crawl up and down slopes, squeeze
through rooms with tight ceilings and scamper over boulders
in a physically-demanding four-five hour tour. The highlight
of the tour is a peek at the Titan Room, where a cluster of
missile-shaped formations grow. The tours are available on
Saturdays and Sundays. The cost is $65 per person plus a
non-refundable $25 deposit. To make a reservation, call (888)
757-2246.

Two original trails — the Dripstone and the Discovery
— lead visitors from room to room of sparkling flow stone,
towering columns, delicate soda straw stalactites and
beautiful crystalline formations. This living cave is only 15
miles northwest of Mountain View. The facility opens at 9
a.m. seven days a week during summer but is open five days
a week from November-April. Guided tours begin at the

visitor center, and times vary for the last tour of the day.

As for overnight accommodations, choose from rustic-
style camping in the Ozark National Forest, Victorian-style
bed and breakfasts in Mountain View or Dry Creek Lodge
on the grounds of Ozark Folk Center State Park. Dedicated
to the preservation and perpetuation of traditional crafts and
music, Ozark Folk Center offers crafts demonstrations, evening
music programs and an on-premises restaurant that serves
home-style cuisine. For information about Ozark Folk Center
State Park, call (501 ) 269-385 1 . For reservations at Dry Creek
Lodge, call (800) 264-FOLK.

For information about camp sites in the Ozark National
Forest, call the state Department of Parks and Tourism, (800)
NATURAL.

Country Oaks Bed and Breakfast in Mountain View caters
to the adult traveler. A farm house and carriage house ofter
accommodations. For information, call (800) 455-2704.

The Inn at Mountain View, a beautifully restored Victorian
home nestled in a quiet residential neighborhood, blends the
best of the past and the present for a lodging experience you’ll
never forget. For information, call (800) 535-1301 .■

Number 4

October 2000 * 137

ADVERTISERS INDEX

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Air Charter Express 131

AMS Benefits Inc Inside back cover

Arkansas Financial Group Inc., The 138

Arkansas Foundation for Medical Care 110

Arkansas Managed Care Organization 114

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Central Flying Service 126

Easter Seals 117

Flake and Kelley Management 112

Guesthouse Inn 127

HealthLink of Arkansas 130

Hoffman-Henry Insurance Corp 134

Hutchinson/Ifrah Financial Services Inc 121

Little Rock Medical Association 131

Maggio Law Firm 119

Medical Protective Co., The 108

Metropolitan National Bank 130

Phy America Physician Services Inc 127

Professionals Advocate Insurance Co Inside front cover

Regions Bank 126

Snell Prosthetic & Orthotic Laboratory 122

State Volunteer Mutual Insurance Co Back cover

Special Publications

Production and Circulation

Publisher

Coordinator

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Jeremy Henderson

Special Publications

Editorial Art Director

Editor- in -Chief

Irene Forbes

Natalie Gardner
Assistant Editor

Advertising Art Director
Matt Stewart

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Advertising Coordinator

Sales Manager
Stephanie Hopkins

Kristen Heldenbrand
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138 • The Journal

Volume 97

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WATS 1-800-542-1058
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e-mail: svmic@svmic.com • Web Site: www.svmic.com • 1-800-342-2239 • (615) 377-1999

RKANS AS MEDICAL SOCIETY CELEBRATES 125 YEARS

THE

Vol. 97 No. 5

November 2000

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NOT IN CIRC.

Medicine
Takes a Turn

From Bartering

to Managed C

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- '— i^-' ' j S-/. — : — |s!— i v. — .■ >

Get Published!

Give something back to your profession...
write an article for

Journal

OF THE ARKANSAS MEDICAL SOCIETY

The journal needs your thoughts and ideas.

So why not consider putting your expertise
and experience on paper?

The Arkansas Medical Society is a statewide
organization that represents all physicians,
regardless of location or type of practice.

The result is a statewide network united for the
common good of the medical profession. The staff
of the Arkansas Medical Society provides members
with the best information and services available.

For information about submitting an article to
The journal of the Arkansas Medical Society,
call Judy Hicks at 501-224-8967
or 1-800-542-1 058.

*ome -Folks seem to think that taking pot shots at physicians is just pood
dean -Fun Vie couldn’t apree less, For 2-5 ye-ars, the. physicians who operate
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possible apainst medical malpractice litipation. As doctors, we know just how
danperous and un-Fair the world really can be. And, with our unrivaled risk
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= 13

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e-mail: svmic@svmic.com • Web Site:www.svmic.com • 1-800-342-2239 • (615) 377-1999

State Volunteer
Mutual Insurance
Company

Volume 97 Number 5
November 2000

Journal

OF THE ARKANSAS MEDICAL SOCIETY

Winner of the A SAE Excellence in Communications Award

CONTENTS

FEATURES

154 Celebrating 125 Years

The Arkansas Medical Society and the physicians it serves
have drastically changed over the past 125 years. Medicine
has gone from the bartering system to managed care, and
training of physicians has increased more and more.

156 The Young and Old

Dr. John Jones of Texarkana is AMS’ oldest member, while
Dr. Cheryll Rich of Corning is the society’s youngest
practicing physician. Both have unique perspectives
on practicing medicine in Arkansas .

1 64 Quality Improvement Programs Depend on Team Work

Over the past several years, the department of family
and community medicine at the University of Arkansas for
Medical Sciences has experimented with ways to incorporate
quality improvement strategies into the family practice
clinical setting. Here, researchers give a report on their
findings .

DEPARTMENTS

149 Commentary

Joseph Beck, MD

151 Letter to the Editor

153 What We’ve Done
For You Lately

1 60 Cardiology Report
170 People + Events

173 Index to Advertisers

174 Arkansas Retreats

On the cover: The doctor’s bag
and stethoscope on the cover was
provided by Dr. Samuel B .
Welch of Little Rock.

Photo: Kirk Jordan

The practice of medicine has come a
long way since the Territorial Days.

— page 154

Dr. John Jones of Texarkana
reminisces about his 55 years
in practice.

— page 156

Number 5

November 2000 • 145

COMMUNICATIONS COORDINATOR

Judy Hicks

EXECUTIVE VICE PRESIDENT

Kenneth LaMastus, CAE

ASSISTANT EXECUTIVE VICE PRESIDENT

David Wroten

EDITORIAL BOARD

Jerry Byrum, MD
Joseph M. Beck, II, MD
Lee Abel, MD
Samuel Landrum, MD
Jerry Kendall, MD
William Ackerman, MD

Pediatrics
Oncology
Internal Medicine
Surgery
Family Practice
Anesthesiology

EDITOR EMERITUS

Alfred Kahn Jr., MD

ARKANSAS MEDICAL SOCIETY
2000-2001 OFFICERS

Gerald A. Stolz, Jr., MD, Russellville
President

Joe Stallings, MD, Jonesboro
President-elect

Paul A. Wallick, MD, Monticello
Vice President

Lloyd G. Langston, MD, Pine Bluff
Immediate Past President

CarltonL. Chambers, III, MD, Harrison/Little Rock
Secretary

Dwight M. Williams, MD, Paragould
Treasurer

Anna Redman, MD, Pine Bluff
Speaker, House of Delegates

Kevin Beavers, MD, Russellville
Vice Speaker, House of Delegates

Joseph M. Beck, II, MD, Little Rock
Chairman of the Council

Established 1 890. Owned and edited by the Ar-
kansas Medical Society and published under the di-
rection of the Council.

Advertising Information: Contact Stephanie
Hopkins, P.O. Box 3686, Little Rock, AR 72203;
(501) 372-2816.

Postmaster: Send address changes to: The Journal
of the Arkansas Medical Society, P. O. Box 55088,
Little Rock, Arkansas 72215-5088.

Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.

The Journal of the Arkansas Medical Society
(ISSN 0004-1858) is published monthly by the Arkan-
sas Medical Society, #10 Corporate Hill Drive, Suite
300, Little Rock, Arkansas 72205 . Printed by The Ovid
Bell Press, Inc., Fulton, Missouri 65251. Periodicals
postage is paid at Little Rock, Arkansas, and at addi-
tional mailing offices.

Articles and advertisements published in The Jour-
nal are for the interest of its readers and do not
represent the official position or endorsement of The
Journal or the Arkansas Medical Society. The Journal
reserves the right to make the final decision on all
content and advertisements.

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November 2000 • 147

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COMMENTARY

St. Vincent

Advocate Fatigue

Joseph M. Beck, II, MD, FACP

More and more lately, I’ve devel-
oped a profound fatigue relating
to certain aspects of my job as a
medical oncologist. I still love the science,
challenge and the gratifying effects the treat-
ments can sometimes produce. These things
are exhilarating. I’ve come to call my par-
ticular type of fatigue “advocate fatigue.”
There are many patient advocates. Each
nurse, pharmacist, physical therapist and
even hospital administrator purports to be
a patient advocate — and many succeed.
However, no one hut the physician sees
the patient regularly over months or years.
No one hut the physician takes a hallowed
oath to ALWAYS do what is best for the
patient (no mention of cost of treatment
in the oath I took or of saving money for
the insurance company stockholders). I
swore that oath seriously and permanently.
And so, as medicine has evolved, so has
my practice of it. Prescribing habits, hos-
pitalization indications, chemotherapy
protocols are all vastly different today than
when I trained 15 years ago.

What has remained exactly the same is
the sick person in the bed depending on
my care and knowledge. What has re-
mained exactly the same is the fact that
the physician bears the ultimate moral and
legal responsibility for what happens to the
patients under his or her care, despite
budget cuts, layoffs, pool nursing or health
maintenance organizations’ medical prac-
tices. What has remained exactly the same
is that while physician judgment concern-
ing patient care issues is questionable and
open to debate by allied personnel during
business hours, that same judgment is sac-
rosanct at night, on weekends and holi-
days — and in court.

And so, as I make my daily journey on
hospital rounds, I find that many things
that once happened routinely because I
wrote an order (not a suggestion or request)
now occur sluggishly or not at all. Since
the patients are still sick and need to be
cared for, this added responsibility falls not
on the hospital administrator or the physi-

cal therapist or even nursing personnel —
whose shifts end at preset times no matter
how dire the situation or how sick the pa-
tient — but on the ultimate patient advo-
cate, the physician. Critical labs are not
called, despite repeated requests, and or-
dered labs are not done. The call lights,
unanswered, are ignored.

One would think that problems as seri-
ous as these would be quickly and effec-
tively acted upon by administrative and
nursing personnel if only they were brought
to the attention of the individuals in
charge. Think again. These problems oc-
cur on a daily basis and are reported fre-
quently. Yellow pads are produced, lists are
generated, promises are made and grand
statements about quality care, partnering,
outcomes and correct nursing matrix fly
about, but nothing changes. Thoughtful
physicians, attempting to take seriously
their oath, prescribe the best drugs for a
particular condition, only to be told by the
pharmacist (who bears no ultimate respon-
sibility for the patient) that the dmg in
question is not on formulary due to the
expense and that a different, possibly less
effective or more toxic medication, will be
used. Patients are forced to bring their own
medications into a tertiary care medical
center, and if they want to receive them
on time and correctly, they or their fami-
lies administer them.

And so I have advocate fatigue. I love
being a doctor and enjoy taking care of my
patients, so I’ll keep making phone calls
and begging ancillary personnel to please
do the job they are being paid to do and
reporting deficiencies to the appropriate
people. But I’m tired. And other excellent
physicians that I am honored to practice
with are tired. But we took that oath seri-
ously, and our patients have no one else,
really, but us. ■

Dr. Beck is an oncologist in Little Rock,
chairman of the AMS Council and a mem-
ber of the editorial board for The Journal of
the Arkansas Medical Society.

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Number 5

November 2000 • 149

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150 ® The Journal

Volume 97

LETTERS

June 12, 2000

Dr. J. David Talley

UAMS Department of Cardiology

Dear Sir:

I am writing this letter to you because
of a recent literature search I did on the
issue of peripartum cardiomyopathy. I noted
a short review article on this subject which
you co-authored, that was in The Journal of
the Arkansas Medical Society in October
1998.

I practice internal medicine and
noninvasive cardiology here in El Dorado
and do most of the echocardiograms. In
the past five months I have done echo-
cardiograms on five ladies — having seen
three of them in consultation — who all
meet the standard criteria for diagnosis
peripartum cardiomyopathy. We have had
279 deliveries during that time. This
calculates to an incidence of one case in
every 55.8 deliveries. This represents a
remarkable increase in the reported
incidences, which you quote in your article
as being between 1,300 and 15,000.
Because of this I have initiated an
extensive chart review on these patients
and have contacted the Arkansas State
Health Department and the Center for
Disease Control in Atlanta. I am hoping
to conduct further investigation and
enlist the assistance of the CDC. I
thought you might he interested in this
information, and certainly I would appre-
ciate any comments or thoughts you
might have on the subject. ■

Sincerely yours,

Alvin Scott Hardin, MD

Correction

In the Women in Medicine issue,
September 2000, it was incorrectly
reported that there was one female
graduate in the University of Arkansas
for Medical Sciences Class of 1980.
Twenty-two women graduated with
the class.

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WHAT WE’VE DONE FOR YOU LATELY

AMS' Political Message
Stays the Same

By Z. Lynn Zeno

Director of Governmental Affairs

Under the heading “what we’ve we done for you lately” the term lately
can be relative. One of the things the Arkansas Medical Society has
done lately for its members is the same service that we have been
providing for the past 125 years. As the AMS prepared to celebrate our 125th
year of service with this special issue, we reviewed documents and past Journals
dating back to our origination in 1875. One of the recurring topics of discussion
was the need to travel to the state’s Capitol and meet with the “Representatives
of the People” to discuss issues relating to public health.

In his 1880 address before the Fifth Annual Session, AMS President Dr.
E. T. Dale told his colleagues, “It is time that the profession should take a
more prominent role in public affairs, be more interested workers for and
promoters of public legislation. It is the duty of physicians, as citizens, to see
that the interests of state medicine are cared for.” That year the AMS lobbied
the Legislature for the creation of a Board of Health (to address the yellow
fever epidemic) and a State Lunatic Asylum. THE MESSAGE AND ITS
IMPORTANCE HAS NOT CHANGED! The only difference is that today
the topics have progressed, or maybe digressed, to issues such as tort reform,
AIDS, Internet medicine and the encroachment of third-party payers upon a
physician’s provision of patient care.

As we celebrate our 1 25 th year, the Arkansas Medical Society will continue
to be the leading advocate for Arkansas patients and physicians. As the director
of governmental affairs, I will continue to lobby and monitor the state and
national legislatures. However, our success ratio vastly improves when every
member physician, their families and their office staffs becomes actively
involved in the process.

Within a few days, on Oct. 29 at the Embassy Suites Hotel in Little Rock,
the AMS will hold its biennial fall meeting to discuss the upcoming 2001
legislative session. This outstanding program will feature a review of
anticipated medical issues to be considered by the Arkansas General Assembly;
a presentation on using the Internet for grassroots communication with state
and federal legislators; and a special session entitled “Politics, Power &. You,”
presented by nationally known political consultant Michael E. Dunn of
Washington, D.C. If you have not registered for this special meeting, please
call the AMS office, (800) 542-1058, or 224-8967 if you’re in Little Rock,
and sign up today. ■

The message today is the same as it was in 1875. IF YOU DON’T TAKE
PART. . .YOU’LL GET TAKEN APART. Get involved in the legislative process
today!

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For Advertising Information,

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Number 5

November 2000 • 153

From Bartering to Managed Care

Medicine Has Drastically Changed Over the Past 125 Years

By Christy L. Smith

R KANSAS’ PHYSICIANS HAVE ALWAYS FACED CHALLENGES — FROM MEDICINE BAGS
minimally equipped with ipecac, opium and a lancet to managed care. To commemorate the

Arkansas Medical Society’s 125th birthday, we offer a brief history of the state’s medical profession.

Today’s physicians must endure extensive and rigorous medical school training in order to receive a

license to practice, but that wasn’t always the case. Prior to the 20th century, a man had only complete an

apprenticeship to practice medicine, Dr. William P. Scarlett wrote in the August 1892 Journal.

The first law regulating physician licensing was not
passed until 1881. Neither a medical degree nor
literacy was a requirement for licensure, which
angered members of the Arkansas Medical Society.
The society activated its Committee on Medical
Legislation in 1892 to draft more acceptable licensing
laws, “the one most effective action ever taken by
our society to protect the welfare of the people and
the physicians of this state,” Dr. Watson said.

Even still, students with only a high school
diploma were being admitted to the state’s medical
school until 1910, according to a time line prepared
by Edwina Walls Mann, former head of UAMS’
history of medical department.

Medical School Evolves

UAMS itself has enjoyed an exciting existence.
The state’s first medical school was founded in 1874
by eight doctors. It was funded entirely by student
fees and contributions, and none of the first 20
students were required to take an entrance exam,
Dr. Watson noted.

The medical school’s enrollment may be nearly
50% women today, but in 1935 only 12 women
were enrolled at UAMS, said Dr. Agnes J. Carpenter
Kolb in a 1995 interview.

“There were six in my class ... We had three
of our professors tell us ... This is no place for
you women,”’ she said.

In 1948, UAMS admitted its first black student,
a woman named Edith Irby, Mann said.

Thirty-seven percent, or 55 out of 150, of the
fall 2000 enrollment was women, said Tom South,
UAMS’ director of admission. And many recent

UAMS opened its doors in 1879 at 113 W.
Second St. in Little Rock.

Volume 97

The state Medical Society held its 36th annual session in 1912 in Hot Springs.

graduates report they were accepted at
the school with open arms.

Changing Medical Issues

The practice of medicine also has
changed drastically in Arkansas. As late as
1918, Arkansas physicians were contending
with epidemics of influenza, Mann recorded.

By this time, morphine and Epsom
salts had found their way into a doctor’s
medical bag. But unfortunately the use
of morphine “made morphine addicts out
of many patients,” Dr. Scarlett wrote in
the August 1982 Journal.

When Dr. Scarlett began practicing
medicine in 1925, surgical procedures
were still rather crude and the number
of specialists was limited, he wrote. Dr.
Scarlett noted that the first heart surgery
was not performed until World War I.

“Now surgeons do all manner of
operations on the heart,” he wrote.

Dr. Scarlett also expressed amazement
at the number of specialists practicing
across the state. In 1925, there was only
one urology surgeon, one lung specialist
and no orthopedic surgeons, he wrote.
In 1982, Dr. Scarlett said there were 784
physicians and “41 types of specialists”
listed in the Little Rock telephone directory.

Today, there are 58 different
specialties and well more than 784
individual physicians and surgeons listed
in the telephone directory.

In fall 1973, the state’s first Arkansas
Area Health Education Center was created
in Pine Bluff, according to an article in
the October 1993 Journal.

Begun as a way to supply family
physicians to rural areas, the agency has
evolved into a six-center health education
network providing direct health care to
residents and a mini-medical center
providing health education to health
profession students, the authors noted.

In the last 25 years, the medical
community has begun dealing with man-
aged care. Many physicians are retiring
early because their time is now spent on
papeiwork rather than patient care.

Interestingly enough, managed care
wasn’t even a glimmer in the eye of
insurance peddlers before 1949, when
Blue Cross was established. During the
Depression, patients did not have
insurance or Medicare to rely on, Dr.
Scarlett wrote. But none were turned away
by the physician, he said.

“We doctors did about as much or
more charity [cases] as pay cases during
the Depression,” said Dr. Scarlett.

The Arkansas Medical Society has
played an important role in keeping
physicians informed about issues such
as managed care. But it is interesting to
note that physicians did not begin
organizing themselves into professional
groups until 1845, when the first local
medical society was established, Dr.
Watson noted.

The Arkansas Medical Society as we
know it today was established in 1875
with 225 members. And since its creation,
the organization has remained steadfast
in its role as an advocate for Arkansas’
physicians. ■

AMS’ Journal Has
Taken on a More
Sophisticated Look

Since it debuted in April 1880,
The Journal of the Arkansas Medical
Society has provided physicians with
information on diseases and laws.

The first issue featured an article
by Dr. T.E. Murrell, who ottered advice
on extracting foreign objects from
patients’ ear canals.

Buttons, seeds, stones, grains of
corn, paper wads, houseflies and
spiders often found their way into the
ear canal, Dr. Murrell wrote.

While most cases could be
treated with a squirt of warm water,
extreme measures such as “turning
the ear down and jarring the head”
were sometimes used, he said.

Advertising found its way into
the publication in June 1906.

The first ad to appear in The
Journalms placed by Detroit-based
Parke Davis Co., peddlers of
acetozone, an intestinal antiseptic
used to treat typhoid fever, diarrhea,
dysentery and cholera.

In September 1 943, Camel asked
Journal readers to send cigarettes to
American servicemen. At the same
time, the Journal made an appeal to
its members younger than 45 to sign
up for military duty.

“The need is so positive that the
questions of essentiality of men in
positions of teaching and research
and in industrial medicine are likely
to be rigidly reviewed," an editorialist
wrote.

By June 1955, about 45 of The
Journal's 68 pages were devoted to
advertising. Of course, The Journal
now devotes more space to editorial,
and the publication’s appearance has
changed, as a result.

The Journal’s generic covers
gave way to glossy photographed
covers in the late 1990s, and articles
on managed care and women
physicians have replaced Dr. Murrel’s
now-humorous look at ear canals.

Number 5

November 2000 • 155

Managed Care Rarely Touched
This Physician’s Life

By Christy L. Smith

DR. JOHN W. JONES OF TEXARKANA NEVER QUESTIONED HIS LIFE’S CALLING.

“I found out a long time ago that the happiest spot is in the OB waiting room. When you
put pregnant women with other pregnant women, they laugh, and they joke with one another.
Pregnant women are a jolly bunch to be around,” he said.

The 93-year-°l(d retired obstetrician and gynecologist delivered his first baby in 1932. He is
the oldest member of the Arkansas Medical Society.

Dr. Jones’ career spanned 55 years, during
which his main focus was always medicine. His
wife, Maiy Jane, raised the children while her

husband saw pa-

Dr. John W. Jones

into the wee hours
of the night. In that day, Dr. Jones said, they
expected no less.

“That was just part of it. I knew
what it was going to be like to be
married to a doctor,” said Mary7
Jane Jones, a former registered
nurse.

Dr. Jones was born in 1907
on a stock farm near Hallsville,

Mo. He said his physician
uncle tried to steer him toward
a career in dentistiy because
medicine demands so
much of a physician’s
time.

“He tried to
tell me that I

really didn’t want to be a doctor because your
time is always somebody else’s. But I didn’t mind
that,” Dr. Jones said.

In 1924, Dr. Jones enrolled at the University of
Missouri at Columbia, about 12 miles away from
his home. He lived on the farm and drove his
Ford roadster to and from class along the dirt and
gravel roads between Hallsville and Columbia. He
was a student assistant at the university and a
member of Phi Beta Kappa honor society. After
graduation, he attended the University of Missouri
medical school for two years before transferring
to Washington University in St. Louis.

In 1933, Dr. Jones moved to Detroit for a
surgical internship at Henry Ford Hospital. He
said he sometimes was on call every other night.
A residency in obstetrics and gynecology
was next on Dr. Jones’ agenda. He began
the residency at Henry Ford but did a
one-year rotation at Duke
University, traveling with
three medical students to
impoverished areas of
North Carolina to de-
liver babies in people’s
homes.

“Students could not
sign birth certificates, and
so I supervised the stu-
dents and signed all the
birth certificates,” he said.

Continued on Page 158

Volume 97

Rural Physician Represents
New Face of Medicine

By Christy L. Smith

DR. CHERYLL RICH IS SOMEWHAT OF A CURIOSITY TO THE 3,000 RESIDENTS OF
Corning, where she practices family medicine at the Family Medical Center.

The 28-year-old physician is the only female doctor within a 30-mile radius, and she works
while her husband stays at home with the children. But the youngest practicing physician of the
Arkansas Medical Society laughs off the stares. She understands that, for many people, she

represents a new face of medicine.

“In the beginning, most of the patients who
scheduled an appointment with me did it to get a
look at the new young, lady doctor. I’ve gotten
used to it. Still yet, I am referred to as the lady

doctor,” she said.

Dr. Cheryll Rich

Rich was raised in
Neelyville, Mo., 10 miles north of Corning. She

November 2000 •

doesn’t remember a time when she didn’t want to
be a doctor.

“I had a sick grandmother, and that just kind
of always stuck with me. I don’t remember ever
wanting to be anything else,” she said.

Dr. Rich received a National Health Service
Corps scholarship to attend medical school at the
University of Missouri, Kansas City. She graduated
in 1996 and completed a family practice residency
in Carbondale, 111., in 1999. Dr. Rich’s employment
in Corning is part of a three-year service obligation
attached to her scholarship.

Now in her second year of practice, Dr.
Rich said she knows she’s different from her
predecessors: She has never worked
outside of the shadow of managed care.
“For me, managed care has always
been there. Yes, it’s frustrating on
some days, but I don’t know
medicine any other way. I had
so much training in residency
as to what you have to do to

Continued on Page 158

157

Dr. Jones

Continued From Page 156

While at Duke, Dr. Jones learned
about a doctor who was building a
new clinic in Texarkana. He worked
as house physician at Parkland
Hospital in Dallas until accepting an
OB/GYN post at Southern Clinic in
Texarkana in 1939. He also joined the
Arkansas Medical Society that year.

Three years later, Dr. Jones found
himself part of the 1st Auxiliary Surgical
Group in the European Theater during
World War II. Based at a hospital near
South Hampton, England, Dr. Jones was
part of a seven-member team that
traveled across Europe tending to
wounded soldiers.

“Most times we had a vehicle, and
we would travel from place to place at
a moment’s notice,” he said.

The small-town boy from Missouri
lived the history that many only read
about in textbooks. He crossed the
bridge at Remagen, Gennany, the only

Dr. Rich

Continued From Page 157
get paid [or] for them not to hassle
you. That was as much of my training
as hands-on with patients. It’s almost
second nature,” she said.

Another noticeable difference,
Dr. Rich refuses to place her family
second to her career, as so many of
her predecessors did.

“This is not my life; this is my
job. I really like my job, and I take it
very seriously, but I’m not a doctor
No. 1. I’m a mother; I’m a wife. And
somewhere down the line [medicine]
falls,” Dr. Rich said.

Dr. Rich is 30 years younger than
the most junior of her three
colleagues. All four are salaried
employees who generally work eight
hours a day, five days a week. None
have call duty because the local
hospital closed nearly a decade ago.

The relatively relaxed work
schedule allows Dr. Rich to spend
more time with her family. Even still,
her husband, Jeny, who has a teaching
degree, has opted to remain at home
with Lauren, 4, and Jacob, 22 months,
until the children reach school age.

bridge across the Rhine River left
standing by the Nazis; he cared for
some of the first casualties from the
Battle of Nonnandy; and he saw British
Prime Minister Winston Churchill speak
on several occasions, experiences that
left a lasting impression.

“Whenever Churchill was speak-
ing, you wanted to listen. Old
Churchill had a wonderful voice ...
He could just buy you out [with his
speeches],” Dr. Jones said.

Dr. Jones returned to Texarkana
following the Japanese surrender in
1945. At Southern Clinic, he met his
future wife, a hometown girl who’s
first husband had been killed during
the war. The two married in 1947
and have two daughters and three
grandchildren.

Dr. Jones continued taking call
duty until 1984, when he was 77
years old. He gave up most of his
OB/GYN patients in 1985, and then
finally retired three years later at the

“It’s good when one parent can
stay at home, and he was really happy
to do that. As a teacher, he would make
about $20,000 a year. By the time you
pay $12,000 a year for day care, it was
a no-brainer,” Dr. Rich said.

Tire bulk of the nearly 3,000 patients
who go to Family Medical Center are
Medicare or sliding-fee patients, and Dr.
Rich focuses much of her time on
women’s and adolescent health.

The clinic also serves as a make-
shift emergency room during working
hours. It isn’t unusual for a minor
fracture, cut or chest pain to interrupt
the normal schedule. But after dark,
things are pretty quiet for Coming’s
four physicians, Dr. Rich said.

“Because the hospital [in Cor-
ning] has been closed for so long,
people are used to calling one of
the nearby emergency rooms [in
Poplar Bluff, Paragould or
Jonesboro] if something happens
after hours. Most of them wait until
8 in the morning when the clinic
opens, if they can,” she said.

Dr. Rich said her work situation
couldn’t be better. And if she has to
work a bit longer than other phys-

age of 80. He said he always knew
he would work until he could work
no longer; early retirement was never
an option in his book.

“No, I never questioned that. [But]
my uncle told me, ‘You better get
out before you are thrown out.’ That
stuck with me. You know when you
can no longer practice. I would get
so tired sometimes standing around
the operating table,” he said.

Dr. Jones said he misses the
doctor/patient relationships he’s
established over the years. He’s glad
he never really had to deal with the
headaches of managed care, and the
biggest change he saw during his
career was the increased availability
of prenatal care, he said.

Dr. Jones estimated that he
delivered 250-300 babies every year
during Inis career. At that rate, Dr. Jones
has delivered about 14,000 babies in
his lifetime, an observation that doesn’t
even make him blink an eye. ■

icians to reap the financial rewards of
her chosen profession, then so be it.

“My commitment is not to do
medicine 24 hours a day, seven days
a week. You go crazy. You have
burnout. I’m content to [practice] a
little bit longer and at a little bit slower
pace,” she said.

Dr. Rich said many of her
medical school classmates shared
that mindset, especially the ones
who chose primary care rather than
a specialty, such as obstetrics.

“When you choose a specialty,
you do it knowing that people’s
appendixes need to come out at 3
a.m., and babies come 24 hours a
day. They choose that different
lifestyle,” she said.

“[The mindset for younger
doctors is] we need to be available,
but we have to have time for
ourselves, also. Medicine used to be
a doctor’s whole life. A lot of times
their families came second. Their
children got to see them when it was
convenient for the patients. It was a
completely different way of life.
Medicine is evolving. There’s no
doubt about it,” she said. ■

158 • The Journal

Volume 97

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Number 5

November 2000 • 159

CARDIOLOGY

Right Ventricular Infarction

Hani A. Razek, MD — EDITOR: Eugene S. Smith, III, MD

A common complication of inferior
wall infarction is right ventricular
infarction. Some aspects of its treatment
differ from standard treatment of
myocardial infarction, making its recog'
nition of great importance. The following
case leads to a discussion of this disorder.

Patient Presentation

68-year-old male with history of
long standing systemic arterial hy-
pertension and diabetes mellitus who
presented with severe substemal chest
pain associated with nausea and
diaphoresis lasting for almost 24 hours.
There was no past history of angina. He
also developed dyspnea on mild
exertion hut denied paroxysmal
nocturnal dyspnea or orthopnea.
Medications included glipizide,
metformin, fosinopril and paroxetine.

Physical examination revealed a blood
pressure of 114/72 mmHg; pulse 95
beats per minute; respiratory rate 22 per
minute. Physical examination was
unremarkable except for mild jugular
venous distention with hepatojugular
reflux. Chest X-ray was unremarkable.
Initial laboratory studies revealed
creatine kinase 311 U/L with MB
fraction of 9 ng/ml and troponin 1 95.5
ng/ml. Electrocardiogram revealed
sinus rhythm with first degree
atrioventricular block and ST segment
elevation of 2-3 mm with pathological
Q waves in inferior leads II, III, AVF
consistent with acute inferior my-
ocardial infarction (fig.l). Right
precordial leads revealed 1-2 mm ST
segment elevation in V3R, V4R, V5R,
and V6R consistent with a con-
comitant acute right ventricular myo-

cardial infarction (fig. 2). Catheter-
ization revealed triple vessel disease
with proximal right coronary artery
occlusion with retrograde collaterals
from the left coronary artery. MUGA
scan with right ventricular first pass
scan showed left ventricular ejection
fraction of 63% with normal wall
motion and a dilated right ventricle
with global hypokinesis and an ejection
fraction of 21%. Patient underwent a
successful four-vessel cardiovascular
bypass grafting.

Discussion

Right ventricular infarction (RVI)
is not diagnosed as often as it occurs. It
accompanies inferior-posterior wall
myocardial infarctions (MI) in 30-50%
of the patients.1 It rarely involves only
the right ventricle (RV). Acute

Fig. 1 . Electrocardiogram revealed sinus rhythm with first degree atrioventricular block and ST segment elevation of 2-3 mm with pathological
Q waves in inferior leads (II, III, AVF) consistent with acute inferior myocardial infarction.

160 • The journal

Volume 97

Fig. 2. Right precordial electrocardiogram revealed sinus
rhythm with first degree atrioventricular block and ST segment
elevation of 1-2 mm with pathological Q waves in right
precordial leads (V3R, V4R, V5R, and V6R) consistent with
acute right ventricular myocardial infarction.

occlusion of the right coronary
artery proximal to the right
ventricular branches results in
dysfunction but not all occlusions
result in RVI. Several factors
account for this including: the
presence of more collateral vessels
from left to right, coronary
perfusion of the right ventricle
occurring in both systole and
diastole, and a lower oxygen
demand of the right ventricle com-
pared to the left.2

Ischemia or infarction of the
right ventricle results in a decrease
in right ventricular compliance,
reduction in filling, and a decrease
in RV stroke volume resulting in
a decrease in left ventricular filling
and cardiac output. In addition to
this, ischemia or infarction of the right
ventricle causes RV dilatation resulting
in a shift of the interventricular septum
to the left as well as causing an increase
in intra-pericardial pressure. This results
in a decrease in the left ventricular
compliance and cardiac output.3

Clinical recognition of acute RVI
is important, as it is associated with
considerable mortality and morbidity.
It should be suspected in any patient
with acute inferior wall myocardial
infarction (IWMI). Its presence
identifies a high-risk subgroup with
potential life threatening consequences.
It should be recognized so that therapies
that lower right heart preload like
nitrates, morphine and diuretics be used
with caution. Atrial infarction, sinus
bradycardia, and atrioventricular block
frequently accompany RVI. The triad
of hypotension, elevated jugular venous
pressure, and clear lung fields has been
recognized as an indicator for RVI in
the setting of acute inferior-posterior
myocardial infarction.4 Pulsus para-
doxus and Kussmaul’s sign have been
reported. The presence of elevated J VP
and Kussmaul’s sign in the setting of
acute IWMI indicates a hemody-
namically significant RVI (specificity
100%, sensitivity 88%). 4 Careful
examination of the jugular venous pulse
serves as an important diagnostic tool.
Patients with intact right atrial function
have enhanced A wave and X descent
with decreased Y descent, but patients

with depressed right atrial function have
depressed A wave, X descent and Y
descent. This finding signifies right
atrial infarct, is a bad prognostic
indicator.2 Tricuspid regurgitation may
result from right ventricle dilation.
High-grade atrioventricular block may
also occur.

Electrocardiogram is the most
reliable and simple diagnostic tool for
diagnosis. In order to diagnose RVI, it
is imperative to obtain right-sided
precordial leads in patients with inferior
wall infarcts. RVI can be diagnosed with
a predictive accuracy above 80% by the
presence of ST segment elevation
greater than or equal to 1 mm in right-
sided precordial lead V4R in the
presence of an acute inferior wall
myocardial infarction. ST segment
elevation in V4R is a strong inde-
pendent predictor of major compli-
cations and in hospital mortality. ST
segment elevation in right precordial
leads is transient and may be absent in
50% of patients with RVI after 1 2 hours
of onset of chest pain.5 Complete
atrioventricular block, right bundle
branch block, and atrial fibrillation are
among the most common dysrhythmias
associated with RVI. Abnormal
echocardiogram findings include right
ventricular dilatation, right ventricular
dyskinesis, reversed septal curvature and
right atrial enlargement. Tire presence
of interatrial septal bowing indicates a
concomitant right atrial infarction

which is an important prognostic
indicator and is a predictor of
hypotension and higher mortality.6
Pulmonary artery catheterization
can confirm RVI by hemodynamic
measurement when the right atrial
pressure exceeds 1 0 mmHg and the
ratio of right atrial pressure to pul-
monary capillary wedge pressure
exceeds 0.8 (normal value less than
0.6). 1

Treatment involves standard
reperfusion therapy for the acute
left ventricular infarction using
thrombolytics or primary angio-
plasty. In patients with hypo-
tension, ventricular preload is
optimized using isotonic saline to
increase right ventricular filling
pressure. Such optimization
usually requires monitoring with
a pulmonary artery catheter. Medica-
tions that reduce preload like diuretics,
nitrates, morphine, and vasodilators
should be used with caution. Once RV
filling pressures are adequate, inotropic
support using dobutamine has been
shown to improve both right and left
ventricular function.3 Inotropic
support should be started if cardiac
output fails to increase after volume
loading. Patients with severe hypo-
tension may require dopamine for
restoration of blood pressure and
perfusion. Maintenance of atrioven-
tricular synchrony is crucial to
maximize cardiac output. If a patient
develops atrioventricular block, atro-
pine may restore sinus rhythm but
some patients require atrioventricular
sequential pacing. Aminophylline has
been reported to restore sinus rhythm
in acute atrioventricular block.'

In summary, RVI occurs in one third
of acute inferior infarctions resulting in
right ventricular dysfunction. All
patients with acute inferior wall
infarction should be evaluated for
concomitant RVI with right-sided
electrocardiogram. Early recognition of
RVI is crucial in the management of
an acute inferior wall infarction.
Avoidance of preload reducing agents
is an important aspect of management.
A majority of patients who survive the
acute phase may have a complete
recovery of right ventricular function

Number 5

November 2000 • 161

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suggesting right ventricular stunning
rather than necrosis as a cause of right
ventricular dysfunction. ■

Drs. Razek and Smith are with the
department of internal medicine , division of
cardiology, UAMS Medical Center and
John L. McClellan Memorial Veterans
Hospital in Little Rock.

References:

1 . Dell’Italia LJ, Starling MR, Crawford
MH et al: Right ventricular infarc-
tion: Identification by hemodynamic
measurements before and after
volume loading and correlation with
noninvasive techniques. J Am Coll
Cardiol 1984;4:931-939

2. Goldstein J A, Barzilai B, Rosamond
TL et al: Determinants of hemo-
namic compromise with severe right
ventricular infarction. Circulation
1990;82:359-368

3. DellTtalia LJ, Starling MR,
Blumhardt R et al: Comparative
effect of volume loading, dobuta-
mine, and nitroprusside in patients
with predominant right ventricular
infarction. Circulation
1985;72:1327-1335

4- Dell’Italia LJ, Starling MR, O’Rourke
RA: Physical examination for
exclusion of hemodynamically im-
portant right ventricular infarction.
Ann Intern Med 1983;99:608-61 1

5. Klein HO, Tordjman T, Ninio R et
al: The early recognition of right
ventricular infarction: Diagnostic
accuracy of the electrocardiographic
V4R lead. Circulation 1983;67:558-
565

6. Lopez-Sendon J, Lopez de Sa E,
Roldan I et al: Inversion of the
normal interatrial septum convexity
in acute myocardial infarction:
Incidence, clinical relevance and
prognostic significance. J Am Coll
Cardiol 1990;15:801-805

7. Goodfellow J, Walker PR: Reversal
of atropine-resistant atrioventricular
block with intravenous
aminophylline in the early phase of
inferior wall myocardial infarction
following treatment with
streptokinase. Eur Heart J
1995;16:862-865

162 • The Journal

Volume 97

Arkansas Behind on National
Quality Improvement Indicators

The Arkansas Foundation for Medical Care, in a
nationwide initiative with the Health Care Financing
Administration and other national quality improvement
stockholders, plans to improve Arkansas’ quality of care by
targeting certain diseases and conditions.

Through the Health Care Quality Improvement Project,

national priorities have been chosen based on public health
importance. These include acute myocardial infarction,
breast cancer awareness, diabetes, heart failure, inpatient
pneumonia, stroke and adult immunization. The following
chart is an overview of where Arkansas stands regarding
these national quality improvement indicators. ■

Arkansas Score Card for National Quality Improvement Indicators I

Arkansas

National

Arkansas

Clinical Topic

Quality Indicators

Rate

Median Rate

Rank

Acute

• Early administration of aspirin

75.1%

84%

50th

Myocardial

• Aspirin at discharge

77.6%

85%

47th

Infarction

• Early administration of beta blockers

55.4%

64%

42nd

• Beta blocker at discharge

62.4%

72%

42nd

• ACE inhibitor at discharge for low ventricular
ejection fraction

56.8%

71%

50th

• Smoking cessation counseling
during hospitalization

24.3%

40%

49th

Pneumonia

• Timely administration of initial antibiotic
at hospital

88%

85%

14th

• Appropriate initial empiric antibiotic
administration

77.8%

79%

32nd

• Blood culture prior to antibiotic administration

82%

28th

• Inpatient influenza vaccination (or screening)

5.9%

14%

50th

• Inpatient pneumococcal vaccination
(or screening)

4.2%

11%

48th

Heart Failure

• ACE inhibitors for low left ventricular
ejection fraction

71.1%

N/A

50th

Atrial

• Warfarin at discharge

50.2%

55%

39th

Fibrillation/

• Antithrombotic at discharge

77.5%

83%

42nd

Stroke/TIA

• Avoiding use of sublingual nifedipine during
acute phase of ischemic stroke

92.2%

95%

35th

Diabetes

• Annual HbAlc

57%

71%

48th

• Biennial lipids

43%

57%

48th

• Biennial eye exam

67%

69%

34th

Adult

• Pneumococcal immunization

39.1%

46%

44th

Immunization*

• Influenza immunization

61.1%

66%

43rd

Breast Cancer

• HEDIS mammography rate

30.72%

N/A

Prevention

• Medicare Biennial mammography rate

49.7%

56%

48th

State rank is based on a total of 53 U.S. states and territories *Source: BRFSS 1 997, Arkansas Foundation for Medical Care

Number 5

November 2000 • 163

SPECIAL ARTICLE

Quality Improvement Programs
Depend on Team Work

Geoffrey Goldsmith, MD, MPH — Kristin Ward, MSPH — Joseph Banken, N, Ph.D. — Judy Grainger, LPN

Introduction

The medical literature documents
the critical need to improve the
quality of care.1 There is little doubt
that physicians and hospitals strive to
provide the very best care, and this
reality has led to an acceleration of
formalized inpatient and outpatient
Clinical Quality Improvement (CQI)
programs over the past decade.

Clinical Quality Improvement as
a process aims to yield the best clinical
practices by reducing practice variance
from best practice standards and
thereby ensures that high quality care
is delivered. Using practice guidelines
derived for clinical experiments and/
or recommendations of expert panels,
achievement of best practices
sometimes takes the form of multi-
prong improvement efforts assembled
into very prescriptive and compre-

hensive disease management pro-
grams.2 Less rigorous approaches use
clinical algorithms that set out prompts
to help the provider choose interven-
tions at key decision points in patient
care. Formalizing a CQI program has
proven effective in improving care in
the ambulatory setting. 3,4

Over the last several years, the
University of Arkansas for Medical
Science’s department of family and
community medicine has been exper-
imenting with ways to incorporate
quality improvement strategies into the
family practice clinical setting. Our goal
is not only to improve our patient care
services but also to train family practice
residents on how to incorporate quality
improvement into the family practice
clinical setting. We now have 12 projects
designed to improve the quality of
clinical practice (see Table 1 ). This paper

presents the issues that we found quite
helpful as we began initiating our quality
improvement program. A review of the
relevant medical literature is intended to
give the reader suggestions that might be
helpful as their site considers establishing
a quality improvement program. We
share with the reader some of our obser-
vations, successes, setbacks and
challenges.

1 . Critical Issues That Affect
the Quality of Care

The Real World of Ambulatory
Medical Practice and CQI

In outpatient practice, the outcome
of care can be influenced by a host of
factors not present or even system-
atically eliminated in the experimental
setting.5 CQI uses evidence-based
medicine (EBM) as a way to standardize

Table 1: Ongoing CQI Strategies in the Department of Family and Community Medicine

ONGOING PROJECTS

• Improve the efficiency of our clinical information system as an essential
foundation for quality improvement

• Create interdisciplinary clinical teams as a strategy to promote best practice
interventions

• Improve availability of medications to medically indigent patients

• Improve patient satisfaction

• Increase patient-centered activities such as improvements in practice
management parameters

• Increase self-care

• Achieve the U.S. Preventive Task Force standards for best practices in
immunization rates

• Achieve national expert panel guidelines for at least two chronic diseases
commonly managed in the family practice setting (diabetes and depression)

• Improve trainees’ prescribing practices for common disorders seen in the
family practice setting

• Build quality improvement training into the residency curriculum

• Identify strategies that can sustain — over the long term — clinical quality
improvement in the family practice setting

• Increase training of medical students in evidenced-based medicine

164 ® The Journal

Volume 97

practice using the most scientific
approach to care management. Since
EBM uses randomized, blinded, pla-
cebo-controlled studies with carefully
defined patient inclusions and
exclusion criteria, generalization of
EBM to primary care practice settings
may be problematic. The other source
for best practices is the use of guidelines
derived from national expert panels.
Such panels’ recommendations may be
far removed from the day to day
realities of primary care.

As one questions how to achieve
best care in family practice, it becomes
apparent that results derived from
tightly controlled experimental studies
(EBM findings) and national expert
panels must be tailored to the real world
of primary care. Early on, we recognized
that our family practice population isn’t
as rigorously defined (“sanitized”) by
diagnosis compared to the rigorous
diagnostic and exclusionary standards
used in scientific studies. Still, having
CQI best practices standards based on
the randomized clinical trials or
national scientific panels is a useful
starting point as one begins to establish
CQI program.6

When patients evaluate quality of
care they consider factors such as
communication skills with their
physician, courtesy of the office staff,
how well the referral was handled to
the sub'specialist, waiting time to
reach the provider and accuracy of
their bill and all other areas of practice
management. These areas too must be
part of a quality improvement program
if one is to attain high quality from
the patient’s perspective. Thus, to be
successful, the entire chain of events
in ambulatory care and the entire
primary care team (clinicians and
office staff) must be considered in a
CQI program.

Organizational Commitment to CQI

Compliance to high standards all
along the care continuum is very
difficult to achieve.7,8 Some corpor-
ations’ almost fanatical leadership
support of total quality improvement
can prove as examples of the very deep
commitment needed to achieve

superior outcomes in medical quality
improvement activities.9

With process issues in mind,
primary care practices need to attend
to the following issues:

• Commitment of the organization’s
leadership to quality improvement;

• Resources allocation for CQI;

• Physician and staff commitment to
weather the short-term failures
mixed with successes that CQI
brings;

• Organizational disruption and
turmoil the redesign of the office
processes that is an early part of

CQI;

• Adequacy of the physician decision
support systems;

• The disbelief within the practice
that there are any significant
problems in clinical care
management;

• Availability of community;
resources to aid vulnerable patients
with chronic illnesses;

• Adequacy of the clinical informa tion
system that supports CQI;

• Adequacy of the data management
system used to assess outcomes; and

• Adequacy of the patient centered
issues that affect compliance and
satisfaction.

Physician Compliance with Practice
Guidelines

The medical literature on quality
improvement points out that some
physicians won’t readily follow
practice guidelines.7,8 Some of the
more common reasons for hesitancy
to follow care guidelines, even if the
guidelines are supported in the
scientific literature, are included in
Table 2. We experienced many of
these issues. One of the most common
beliefs of physicians is their current
medical practices are very good and
there isn’t a need to invest the time
(which is considerable), cost (which
can be significant) and disruption of
the current care system (which may
be modest to dramatic) that often is
entailed in CQI programs. In dealing
with this issue, one should know that
physicians may not understand their
knowledge shortcomings.10 Studies

also show that providing physicians
feedback on practice activities provide
a wealth of useful information that
may improve care.11

Physicians may not implement a
guideline or disease management
system because of “lack of outcome
expectancy.” That is, even if the new
disease management system was
endorsed as having the potential to
improve outcomes, physicians believe
that factors beyond the control of the
physician may influence the
probability that the change will have
its intended effect.12 This is based on
the belief of many physicians that
recommendations from national
panels and/or clinical trials won’t
“work in the real world of my
practice.” The use of examples from
like practices that were able to achieve
better outcomes helps to address this
concern.

Awareness, agreement, adoption
and adherence must be addressed step
by step with providers in order to
change the norm of the practice group.
Guidelines change over time and must
be updated. Adherence to changing
standards needs continuous attention
(measure outcomes + reevaluate the
change + reinforce the change +
change the strategy changed if com-
pliance isn’t yielding better patient
outcomes + re-teach staff and clinicians
about the standard) if a guideline is to
improve care. This has been a major
issue in our practice and hardest part
of the CQI process. Working on
adherence isn’t as much fun as the
group enthusiasm for new project
development. Thus, philosophical
adoption of a guideline by the practice
physicians is only the first step to
incorporating a long-term change into
the day to day procedures of the
practice.

It Takes a Team to Achieve
Extraordinary Ambulatory Care

Our clinical experience and that
of others is that it takes team effort to
maintain high quality care.13 This
means the office staff not only need
to embrace the opportunity to make
improvements but just like providers,

Number 5

November 2000 • 165

1 Table 2: Common Reasons Quality Improvement Fails in Medical Settings 1

Physician-related

Patients

Ancillary staff

Don’t agree that CQI is needed in
the clinic

Don’t believe their efforts/ideas
will matter

Don’t agree that CQI is a mision of
mission of the clinic

Lack of awareness of a guideline

Not motivated in self care and
their role

Not aware of practice guideline

Disagreements with guidelines

Lack of resources to implement to
provider’s plan

Disagreement about whether
change is part of their job

Belief that even if the guideline is
followed, it won’t change the
quality of care

Don’t believe in the treatment
plan but afraid to speak up

Lack of assurance that office
change will lead lead to the
desired change

Resistance in being told what to do

Lack of understanding of the plan

Resistance to change

No incentives or disincentives
driving change

Lack of incentives to change

No incentives to change

Late adopters are naturally hesitant
to change practice patterns

Weren’t asked to participate actively
in their care

Not willing to lead change

Lack of training inhibits acceptance
of practice change (skills and/or
knowledge deficit)

Inadequate patient education
(knowledge deficit)

Inadequate training of
ancillary staff

Lack of feedback, prompts and
reminders that signal a change is
needed

Lack of social support to implement
the plan

Lack of feedback, prompts,
and reminders

The medical system makes it
difficult to adopt quality protocols

Lack of skills to implement the plan

Just too busy to invest time in
making changes

staff need to understand the rationale
for new approaches and have incen-
tives to improve quality. Table 2 lists
common issues that emerged as our
practice adopted CQI programs.

Over time, human resources
policies can lead to promotion and
retention of staff who espouse and
move the quality agenda forward.

Attention to Patient-Centered Care
Will Improve Quality

In addition to getting the providers
and staff “aboard” on the quality
improvement journey, one can’t sail
without attending to the importance
of patient-centered strategies. As is
typical for primary care practice,
many patients have chronic diseases
such as hypertension, high choles-
terol, diabetes, coronary artery
disease, musculo-skeletal pain and
asthma. Most ambulatory chronic
disease management depends on the
patient and/or family to implement
the care program. It is easy to see
that even the best designed practice
guidelines can be undone by the
non-compliance to the treatment

plan. For example, studies on non-
compliance with medications in
hypertensives cite that about 50% of
the reason our treatment doesn’t
work is due to patient non-com-
pliance.14 Patient-centered reasons
patients don’t achieve best outcomes
appear in Table 2.

2. Strategies That Can Be
Used to Enhance Quality

Redesign the Practice and Creation
of a Decision Support System

In an office that uses a paper-
based medical record system, chart
audits are very costly and difficult to
perform. Yet, an absolute requirement
for quality improvement efforts is to
perform chart audits. The paper chart
audits can show opportunities to
improve practice patterns and is
certainly a reasonable approach for a
non-computerized practice to start its
CQI program.

Using the cumbersome and costly
manual paper chart audit system, we
rapidly came to the conclusion, that
over the long term, an electronic

medical record (EMR) is an essential
tool for quality improvement. The year-
long EMR implementation process we
used at our site is described in detail in
an article in Medical Economics.15 The
result of adopting an EMR is that we
improved our ability to monitor the
quality of care, added quality im-
provement strategies into the software
and dramatically reduced the cost of
supporting quality improvement.
Using the EMR, we now are able to
do chart audits in one tenth the time
and cost of manual surveys. We can
query the EMR to structure quality
reviews on patients fitting unique
quality improvement topics of interest.
An example is that a CQI survey might
be designed to, “Find all patients ages
50-60 and check when they last had a
flexible sigmoidoscopy or colonoscopy.”
We then can focus on deciding whether
we should improve compliance with
our standards for bowel cancer
screening in this group of patients.

The EMR is now able to tailor an
immunization prompt for each patient
adjusted by the age and sex of the
patient.

166 • The journal

Volume 97

A very thorough study by the
Health Care Finance Administration
of 197 papers evaluating18 strategies to
change clinical behavior found that
most effective strategies to improve
clinical performance in the medical
office involved office redesign,
including prompts and reminders,
patient notification systems, feedback
to providers about their performance
and standing orders.16 These redesign
issues can be accomplished first
through having the office agree upon
standard operating procedures and
then through the use of an EMR. The
above study was concerned with
immunizations but practice redesign
approaches have been found to be
successful with chronic disease
management.13 We learned that even
using such approaches to improving
immunizations, the best redesign
system can be defeated. We failed to
monitor the patient outcomes
regularly enough, paid inadequate
attention to reeducate the office how
to use the redesign and didn’t tie
human resources incentives closely
enough to the change on outcomes.
But with time, when initial attempts
at improvements failed we tried other
approaches.

Data Management Systems

The EMR is an excellent aid for
improving the quality of care but it is
just one part of a CQI system. Most
EMRs are not robust enough to
support a CQI program’s data manage-
ment needs. A key factor in improving
chronic disorders is to create a registry
of patients with a particular disorder.
This allows one to set a practice’s base-
line care and to compare improvement
as the practice changes its care
systems. Access, Excel or SPSS can be
used to enter and manipulate data in
a small to moderate size practice. Such
a data management system is another
needed component of an office-based
CQI program.

We are experimenting with Web-
based data storage and analysis tools
supplied by a national health out-
comes company that allows our
practice to compare our practice

parameters in the care of depressed
patients to other sites.17

Using Educational Strategies to
Change Physician Behavior

As one initiates a quality improve-
ment program, there is a seductive
notion that all the practice needs to do
to achieve improved practice outcomes
is to improve the knowledge base of the
family physician. Lectures (passive
learning) linked with active strategies
(office changes, clinical audits or
administrative changes) is one way to
change clinical behavior.4,18 But
improving clinicians’ knowledge about
best practices guideline may not be ade-
quate to generate practice changes.19,12
One needs to combine knowledge
improvement and practice changes.

Rational decision making theory
would argue that the physician will do
what is rewarded as long as the result
is efficacove adoption of change.

According to research on change,
people appear to fall into various
categorie in terms of the rapidity they
incorporate change into their work
activities.24 There are the individuals
who just don’t want to be “hassled”
with inconvenience of changes.
Others who aren’t leaders of change
look to the formal and informal leaders
for cues and permission to make
changes. Then there are late adopters
that some term “laggards” in the
medical setting.24 Others may consider
them as “resisters.” They want and
need lots of information before they
are convinced of the value of change.
Unless the resisters are in positions of
power, it is best to leave this group to
the last. After most of the kinks in the
CQI system have been resolved, their
resistance is often less vigorous —
some resisters may have even
converted to adopters by then. We
found that incentives to bring along
resisters include peer pressure, adding
lots of educational support in coping
with the change, making change
gradual and finally make it difficult to
continue to do things the old way.

Organizational management
theory points out that in managing
change, one must consider the

organization’s power hierarchy (how
are decisions made) and sources of
support and resistance once a decision
is made (determines how successful
implementation will be). A four
quadrant grid can be constructed with
“organizational power” on one axis
and level of support (organizational
resistance to enthusiastic support) on
the other. In quadrant one, resides
physicians and administrative staff
with high power and high support for
CQI. One is well served to work
hardest at first in this quadrant. That
is, one aims to influence physicians
and administrators who have the
highest power (authority, either formal
or informal) and lowest resistance to
change. This is preferable to aiming
initially in the other quadrants (low
power and high support, high power
and low support and high power and
high resistance).

Leadership support is essential for
sustaining quality improvement.
Improving quality involves a gradual
set of “experiments” that progressively
result in improvement. One starts a
quality improvement project with the
hope a small project might improve
care. If the pilot is successful, the
practice expands the trial eventually
incorporating the improvements into
the usual practice pattern. If the pilot
is a failure, one must have the
practice’s support to continue the
improvement process by trying other
“experiments.” CQI strategies can
yield great long-term gains but here are
many people who, at the first sign of a
pilot experiment that fails to improve
care, will argue to go back to what has
worked in the past and drop CQI efforts.
Support from the senior leadership is
essential to reinforce the value of
continuously striving for long-term
clinical improvements and protecting
the CQI budget along the way.

Patient-Centered Strategies

Patient-centered activities include
adapting the practice to patients’ needs,
empowering the patient through self-
care and providing patient assistance
through use of community resources.
Most primary care practices can’t afford

Number 5

November 2000 • 167

a social worker to mobilize community
support networks to aid them in the
management of their chronic diseases.
Yet, many primary care patients lack
the resources and social support systems
to aid them in the management of their
disorders. It is essential to craft together
community resources if one is to
optimize management of chronic
diseases in vulnerable patient popu-
lations.13 Self-care can be taught to
patients by ancillary staff or the
physician but patient education
services aren’t well reimbursed.

As we reviewed the medication use
of many of our patients with chronic
disorders, it became clear that a large
number of patients couldn’t afford the
medications we prescribed. The need
for free medications far outstripped our
sample cabinet capacity. We targeted
this area as a top priority for improving
our patient-centered care strategies.
Working closely with our College of
Pharmacy and pharmaceutical
companies, we implemented a free
medication program (called the patient
assistance program) for patients who met
the pharmaceutical companies’ financial
need criteria. Any private practice can
establish a similar program making use
of the office staff to support the
administrative workload.

Over the past year, the first year of
the free medication program, $106,000
in free medications were provided for
our most needy patients — about 5.5
times the cost of the program. Now in
the second year of the program, the
utilization is increasing by about 50%.
We have developed administrative
systems that will allow us to increase
the amount of medications we provide
without adding any staff costs. The
result of the free medications program
has been a dramatic improvement of
compliance with medication use.
Interestingly, a local television station
did a news story on our free medi-
cations program and this yielded
hundreds of patient calls to us. We
signed up many patients for our
teaching practice who had health
insurance but no medication coverage.
This was a very unexpected and
positive outcome for our residents’
practice panel and addressed a needed

community service. Some private
physicians make use of this approach
to providing their patients with
medications and pay for the staff cost
by charging a small administrative fee
to do the paperwork.

Patients who don’t understand their
physician’s instructions aren’t likely to
follow even the best-designed treat-
ment plan, even when the medications
are free. One study of diabetic patients
showed that the reasons for non-
compliance patients included: dietary
issues ( 2 5 % ) , cost ( 1 7 % ) , forgetfulness
(14%), time and lifestyle (20%) and
complicated dosing.25 Other studies of
elderly show that up to one-third of
elderly patient’s illiteracy impairs their
medical care.26 It is critical to tailor
patient instructions to the patients’
education level. For example, practices
that provide patients with medical
information about immunizations
written at fifth-grade level are able to
dramatically improve compliance.27 As
a priority in the area of self-care, we
have adopted patient education as
another part of our patient centered
practice activities. We have a com-
bination of patient educators, nurses,
PharmDs and our clinicians who provide
these services and are able to recover part
of the costs for such care through close
attention to proper coding.

Lessons and Future Directions

Simplicity in quality improvement
has been noted to be an essential
ingredient of successful projects.28 This
has been our experience as well. We
are using an Internet-based module
created by the Centers for Outcomes
Research.17 This module is simple,
straightforward and easy to use. The
screening questionnaire we now use
contains three items and does not
require scoring. At a glance, the nurse
or doctor can decide if further testing is
necessary. This is the kind of approach
that is most likely to be adopted.

Use of clinical guidelines and
standing orders must not replace good
clinical judgment. In fact, over-
reliance on computerized prompts
and standing protocols without
regular reviews and training of staff
can open the practice into a signi-

ficant problem. For example, an audit
of pharmacy computer systems to
prevent medication errors found a
host of missed opportunities to pre-
vent problems and just plain over-
sights in over 60% of the systems
tested, according to the Institute for
Safe Medication Practices.29 Our own
experience is that CQI is a constant
active learning process that requires
substantial feedback to ensure that the
approaches being used are affecting
positive changes. We decided to do a
modest amount of evaluation (patient
satisfaction measures, chart audits of
care, productivity measurement in the
free medication program, productivity
and quality of the CME programs and
educational program evaluation). This
approach had a significant downside.
It is difficult to use a quantitative
approach to deciding which CQI
project should be supported with
scarce resources. In areas where we
didn’t regularly measure patient
outcomes (for example, immunization
rates), we could not quickly change
our CQI strategy. In our third year of
the CQI project, we plan to do far
more intensive evaluation.

It is clear that changing physician
behavior is a very difficult assignment.
There seems to be a counterbalancing
“spirit” in any practice that can undo
CQI strategies unless energy is made
to maintain the improvements. But
with adequate attention to the ration-
ale for such change, a well thought out
step-by-step approach to address
physicians’ concerns, an adequate
educational support and incentives, we
found that progress can be made.

In most primary care practices,
quality of care efforts aren’t reimbursed
with incentives. It may be difficult to
support the costs of a comprehensive
quality improvement program within
an office-based primary care setting
without financial incentives to do so
although portions of a CQI appear to
be sustainable. ■

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Management, 20, 4, 74-86, 1997.

22. Greco P J, Eisenberg J M, Changing
physician’s practices. NEJM 329:
1271-1273, 1973.

23. Kanter R M, From status to
contribution: Some organizational
implications for the changing basis
for pay. ACEP Executive Brief: 64,

1, 12-27, 30-37, January, 1987.

24- Steffensen FH, Sorensen HT, and
Olesen F, Diffusion of new drugs in
Danish general practice, Family
Practice, vol. 16, no. 4, 407-413, 1999

25. Novo Nordisk, in Physicians
Financial News, 5, January 15, 1999.

26. McKinney M, Medicare Patients’
illiteracy impairs medical care,

Medical Tribune, 19, March 18, 1999.

27. Jacobson TA, Thomas DM, Morton
FJ, et. al., Use of low-literacy patient
education tool to enhance
pneumococcal vaccination rates: a
randomized controlled trial, JAMA,
vol. 282, no. 7; 646-650, August 18,
1999.

28. Angstman G, Simplicity leads to
success with guidelines, Medical
Management Network, 5, 10, 1,
Medical Management Network,
November 1997.

29. Practice Beat, Many Rx errors slip
past hospital computers, Medical
Economics, 28-34, July 26, 1999.

Let

Hear

From

You!

You can now e-mail AMS
at the

following addresses:

Main address:

ams @ arkmed.org
Ken LaMastus:
klamastus @ arkmed.org
Lynn Zeno:
zeno @ arkmed.org
David Wroten:
dwroten @ arkmed.org
Kay Waldo:
kwaldo @ arkmed.org
Journal:

journal @ arkmed.org

Plus. . .

Visit our web site at:

www.arkmed.org

Number 5

November 2000 • 169

PEOPLE+EVENTS

HONORED

Dr. Shock Appointed
UAMS Interim Dean

Dr. John P. Shock has

been named interim dean of
the University of Arkansas for
Medical Sciences’ College of
Medicine.

Dr. I. Dodd
Wilson, cur-
rent dean of
the college,
will succeed
Dr. Harry P.

Ward as
chancellor of UAMS.

Dr. Shock will take over
dean duties in mid-October.
The search for a new dean will
begin soon and follow the
traditional academic executive
search process. As interim
dean, Dr. Shock will handle
the day-to-day responsibilities
for the dean’s office, maintain
his role as chairman of the
department of ophthalmology
and continue to see patients
weekly.

UAMS Physician Heads
Orthopedic Group

Dr. Carl Nelson, chair-
man and a professor of the
department of orthopedic
surgery and the director of the
Center for Hip and Knee
Surgery at UAMS, has been
named president of the Mid-
America Orthopedic Associ-
ation.

Little Rock Physician
Profiled in Magazine

Dr. Nicholas J. Paslidis

of Little Rock was profiled in
the April 10 issue of Medical
Economics.

The article focused pri-
marily on Dr. Paslidis’ work

with White River Rural
Health Centers, a network of
12 primary care clinics serving
older and indigent patients in
Searcy, Kensett, Des Arc and
Hazen.

The Greek native com-
pleted medical school in the
United States and earned a
doctoral degree in molecular
biology before beginning an
internal medicine residency
at the University of Texas at
Houston. In 1995, he moved
to Boston with his wife and
two daughters for a fellowship
in gastroenterology at Har-
vard Medical School. He
planned on a career in aca-
demic medicine but experi-
enced a change of heart six
months into his fellowship.

The pace of his practice
for the last five years has been
hectic. Dr. Paslidis works an
average of 18 hours a day and
drives an average of 200 miles
each day.

Dr. Golden Elected to
Internal Medicine Society

Dr. William E. Golden,

an internist and geriatrician,
has been elected to the board
of regents of the American
College of Physicians- Amer-
ican Society of Internal
Medicine. A graduate of Bay-
lor College of Medicine, Dr.
Golden is the director of
general internal medicine
and professor of medicine for
UAMS.

Dr. Ross Certified as
Medical Review Officer

Dr. R.W. Ross of Corner-
stone Family Clinic in Van
Buren recently became certi-
fied as a medical review
officer.

The American Associ-
ation of Medical Review
Officers Inc., created in 1991,
is a nonprofit medical society
dedicated to establishing
national standards and certifi-
cation of medical practitioners
and other professionals in the
field of drug and alcohol testing.
This certification process has
involved training programs, the
establishment of standard prac-
tices and procedures and the
administration of voluntary
certification examinations.

Dr. Ross is the medical
director of the Cornerstone
Medical Group and Ozark
Medical Arts in Ozark.

Dr. Davis Inducted
into Honor Society

Dr. R. Keith Davis of El

Dorado recently was induc-
ted into the Alpha Omega
Alpha national honor med-
ical society at a April 18 ban-
quet held to honor new mem-
bers at the Pleasant Valley
Country Club in Little Rock.

Alpha Omega Alpha is
the only national honor
medical society in the world.
Its purpose is to recognize and
perpetuate excellence in the
medical profession.

Dr. Davis currently is
completing a three-year resi-
dency program in family prac-
tice at the El Dorado AHEC.

EVENTS

New Prostate Cancer
Foundation Wages War

The Arkansas Prostate
Cancer Foundation needs the
help of individuals, organiza-
tions and institutions across
Arkansas to continue waging
its war on prostate cancer.

Prostate cancer is the
most commonly diagnosed
cancer in men. American men
have a one in six lifetime risk
of developing the disease, and
the risk rises dramatically
with age. For instance, by the
time a man reaches the age
of 50, there’s a 30% chance
he has prostate cancer.

The goal of the Arkansas
Prostate Cancer Foundation, a
nonprofit advocacy group for
residents of the state of Arkan-
sas, is to raise the awareness of
the high risk of prostate cancer,
to facilitate early diagnosis and
to improve treatment. To
accomplish this, the foundation
supports education, research
and treatment programs and
facilities throughout the state.

The foundation was the
vision of James C. East and
Dr. Graham F. Greene, both
of Little Rock.

The foundation is cur-
rently soliciting leadership
contributions. Become a
founder, partner, sustainer,
benefactor or supporter by
making a pledge to the Arka-
nsas Prostate Cancer Founda-
tion, PO. Box 7317, Little
Rock, AR, 72217. For more
information, (501) 603-7433.

Community Match
Program Adds Towns

At a recent Rural Med-
icine Student Leadership
Association luncheon in Lit-
tle Rock, 14 UAMS medical
students and nine Arkansas
communities made a mutual
commitment. Each commun-
ity will sponsor a student by
paying half of his or her med-
ical school expenses, about
$8,250 a year for four years.
The state will pay the other

Dr. Shock

1 70 • The journal

Volume 97

half. In return, the student will work as a
primary care physician in the sponsoring
community for four years following his or
her graduation and residency.

Thirty-nine communities currently
participate in this Community Match
Program. Six new communities will be
added this fall.

Enacted by the state legislature in
1995, the program differs from the older
rural loan programs because it carries stiff
penalties for those students who do not
fulfill their contract.

UAMS students attending the
luncheon and where they will practice:
Barry Pierce, Stuttgart; Bill Cobb, New-
port; Garrett Sanford, Newport; Sidney
Collins, Monticello; Nicole Bowen,
Tuckerman; Jason Vanderburg, Brinkley;
Stacy Crider, Newport; Justin Hayes,
Booneville; Brian Oge, Nashville; Garry
Stewart, Perryville; Jeff Graham, Osceola;
Brannon Treece, Osceola; and Ken Dill,
Osceola.

RETIREMENTS

Des Arc Doctor Retires
After 53 Years

Dr. Gerald M. Schumann of Des

Arc recently retired after 53 years of
service to the community.

He was honored with a plague and
several personal gifts by staff at the
White River Medical Center.

Dr. Schumann, who is known around
town for the many ball caps he wore at
the office, gained national recognition
when he was named the No. 2 “Country
Doctor of the Year” two years ago.

He came to Des Arc in 1946 after
receiving his medical degree from
Columbia University in New York City.
Before heading to Des Arc, Dr. Schu-
mann served as a surgeon in the U.S.
Army during World War II. At one
time, he opened a hospital in Des Arc.
It closed after facilities in nearby towns,
such as Searcy, began to grow. But the
Schumann Clinic remained open at
Third and Main streets. The building
is now deeded to the city of Des Arc.

West Memphis Doctor
Honored By Community

Dr. Chester Peeples, an internal
medicine physician in West Memphis,
was recently honored with a retirement

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Number 5

November 2000 • 171

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Arkansas Medical Society’s

Physician’s Legal Guide

Be one of the first to obtain this guide which contains a
miltitude of state and federal laws
affecting the practice of medicine.

This guide is a valuable resource for
physicians, clinic and hospital
administrators, office staff, attorneys,
regulators and many others.

Check enclosed in the amount of: $_

$A^00*

UJ“

members

$0700*

(3 / List Price

Prices include
shipping and handling.

Please charge my Visa or Mastercard:
Cardholder’s name:

□

Please check if you are an
AMS member.

Credit card No.:

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Cardholder’s Signature:,
Name:

Clinic:

Address:

City:,

State:

Zip:,

Phone: ( ).

Fax No.: (

CREDIT CARD ORDERS CAN BE FAXED TO: (501 ) 224-6489

Call the AMS office at 501-224-8967 or 800-542-1058 for volume discount pricing.

party celebrating his 38 years of service
in Crittenden County.

Ross Hooper, chief executive officer
of Crittenden Memorial Hospital, pre-
sented Dr. Peeples with a plague
honoring his service in West Memphis.
With his newfound time, Dr. Peeples
plans to enjoy Lake Hamilton in Hot
Springs, fish at East Lake, attend
Redbirds baseball games and watch his
grandchildren’s ball games.

Dr. Peeples attended medical school
at the University of Tennessee and spent
two years in the Air Force as a flight sur-
geon.

Dr. Peeples will remain medical
director of the recuperative clinic at
Crittenden Memorial Hospital and
plans to run for reelection to the West
Memphis City Hall this fall.

OBITUARY

Stanley R. McEwen, MD

Dr. Stanley R. McEwen, 73, died
June 1 in Fort Smith.

Dr. McEwen was the founding
member of the Ophthalmology Clinic
in Fort Smith, which is now the Eye
Group. He first started practicing in
Greensburg, Kan., after two years as a
general medical doctor in the Navy
during the Korean War. He was chief of
ophthalmology service at Veterans
Hospital at Kansas City, Mo.

He began college at Tulane Unive-
rsity in New Orleans and graduated from
Kansas University Medical School. He
completed his residency training at KU.

Dr. McEwen was a retired Navy
commander, patron member of the
National Rifle Association, a life
member of the Old Fort Gun Club,
member of the Noon Civics Club and
member of the American Medical
Association, Arkansas Medical Society,
American College of Surgeons, Society
of Military Ophthalmologists and
American Academy of Ophthalmology.
He was a member of the Sons of the
American Revolution, Phi Delta Theta
fraternity and past member of the Fort
Smith Girls Club board.

Dr. McEwen is survived by his wife,
Anne Stodder McEwen; one son, Fred
J. McEwen of Fort Smith; one daughter,
Kelsey Alexander of Custer, S.D.; and
three grandchildren. ■

1 72 • The Journal

Volume 97

ADVERTISERS INDEX

AMS Benefits Inc 152

Arkansas Financial Group Inc., The 150

Arkansas Foundation for Medical Care Inside front cover

Asti, William Henry, AIA 149

Central Flying Service 151

Emcare 162

Farmers Healthcare Professional Liability 148

Guesthouse Inn 151

HealthLink of Arkansas 171

Hutchinson/Ifrah Financial Services Inc 159

Little Rock Medical Association 172

Maggio Law Firm 159

Mary Healey’s Fine Jewelry 147

Medical Protective Co., The 146

Metropolitan Investment Professionals 147

PhyAmerica Physician Services Inc 150

Professionals Advocate Insurance Co Inside back cover

Regions Bank 162

Smith Capital Management 171

Snell Prosthetic &. Orthotic Laboratory Back cover

St. Vincent Health System 149

State Volunteer Mutual Insurance Co 144

Special Publications

Editorial Art Director

Publisher
Brigette William

Irene Forbes

Advertising Art Director

Special Publications
Editor- in -Chief

Matt Stewart

Natalie Gardner

Advertising Coordinator
Kristen Heldenbrand

Assistant Editor

Christy L. Smith

Marketing Assistant
M itzi Tiffee

Sales Manager

Database Administrator

Stephanie Hopkins

Account Executive
Liz Earlywine

H.L. Moody

▲ ARKANSAS BUSINESS

Director of Design &
Circulation

PUBLISHING GROUP

Virgeen Healey

Chairman & Chief Executive Officer
Olivia Farrell

Director of Marketing

President and Publisher

Allison Pickell

Jeff Hankins

Executive Vice President

Production and

Sheila Palmer

Circulation Coordinator

Jeremy Henderson

www.abpg.com

Statement of Ownership, Management, and Circulation

United States PostaJ Service

Statement of Ownership, Management, and Circulation

1 . Publication Title

THE JOURNAL OF THE
ARKANSAS MEDICAL SOCIETY

2. Publication Number

3. Filing Dale

o|2 |8 |3 | - | 8 | 6 | 0 | 0

09-30-00

4. Issue Frequency

5. Number of Issues Published Annually

6. Annual Subscription Price

Monthly

$30.00

7. Complete Mailing Address of Known Office of Publication (Not printer) (Street, city, county, state, and ZIP +4)

#10 Corporate Hill Dr., Suite 300
Little Rock, AR 72205

Conlact Person
Telephone

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#10 Corporate Hill Dr., Suite 300
Little Rock, AR 72205

9. Full Names and Complete Mailing Addresses of Publisher, Editor, and Managing Editor (Do not leave blank)
Publisher (Nameand complete mailing address) Arkansas Medical Society

#10 Corporate Hill Drive, Suite 300
Little Rock, AR 72205

Editor (Nome and comp/bto malting address)

Managing Editor (Name and complete mailing address)

Judy Hicks, Communications Coordinator
#10 Corporate Hill Dr., Suite 300

Little Rock, AR 72205

1 0. Owner (Do not leave blank. If the publication Is owned by a corporation, give the name and address of the corporation Immediately followed by the
names and addresses of all stockholders owning or holding 1 percent or more of the total amount of stock. If not owned by a corporation, give the
names and addresses of the Individual owners, downed by a partnership or other unincorporated firm, give its name and address as well as those of
each Individual owner. If the publication Is published by a nonprofit organization, give its name and address.)

Full Name

Complete Mailing Address

Arkansas Medical Society

#10 Corporate Hill Drive, Suite 300
Little Rock, AR 72205

11. Known Bondholders, Mortgagees, and Other Security Holders Owning or
Holding 1 Percent or More of Total Amount of Bonds, Mortgages, or

Other Securities. If none, check box ► H None

Full Name

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1 2. Tax Status (For completion by nonprofit organizations authorized to mall at nonprofit rates) (Check one)

The purpose, function, and nonprofit 3tatus of this organization and the exempt status tor federal Income tax purposes:
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□ Has Changed During Preceding 1 2 Months (Publisher must submit explanation ot change with this statement)

PS Form 3526, September 1998 (See Instructions on Reverse)

13. Publication Title

THE JOURNAL OF THE ARKANSAS
MEDICAL SOCIETY

14. Issue Date for Circulation Data Below

July/' -August 2000

15.

Extent and Nature of Circulation

Average No. Copies Each Issue
During Preceding 12 Months

No. Copies of Slngl» Issue
Published Nearest to Filing Date

a. Total Number of Copies (Net press run)

4495

4452

(1)

Pald/Requesied Outside-County Mall Subscriptions Staled on
Form 3541. (Include advertiser's proof and exchange copies)

2877

2922

b. Paid and/or

(2)

Paid In-County Subscriptions (Include advertisers proof
and exchange copies)

Circulation

(3)

Sales Through Dealers and Carriers, Street Vendors,
Counter Sales, and Other Non-USPS Paid Distribution

(4)

Other Classes Mailed Through the USPS

c- Total Paid and/or Requested Circulation [Sum ot 15b. (1), (2), (3), and ^
(4)1 r

2877

2922

“"Free

Distribution

(1)

Outside-County as Stated on Form 3541

by Mall
(Samples,
compliment
ary. and
other free)

(2)

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(3)

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1441

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Total Free Distribution (Sum of 15d. and I5e.) ►

1441

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® Total Distribution (Sum of 15c. and 15/) ^

4318

4271

Copies not Distributed

177

181

Total (Sum of I5g. and h.) ^

4495

4452

I- Percent Paid and/or Requested Circulation
(15c divided by 15g. times 100)

67%

68%

16. Publication of Statement of Ownership

XXE1 Publication required. Will be printed In the November 2000 issue 0f this publication, □ Publication not required.

17. Signature and Title of Editor, Publisher, Business Manager, or Owner

ijccfu? , Cmn/iULi UdLU-ni^

9// ‘j/oO

I certify mat all Information furnished on this form Is tr
or who omits material or Information requested or "
(Including civil penalties).

Instructions to Publishers

1 . Complete and file one copy of this form with your postmaster annually on or before October 1 . Keep a copy of the completed form
for your records.

2. In cases where the stockholder or security holder Is a trustee, Include In items 10 and 11 the name of the person or corporation for
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3. Be sure to furnish all circulation Information called for in Item 15. Free circulation must be shown In items 15d, e, and f.

4. Item 15h., Copies not Distributed, must Include (1) newsstand copies originally stated on Form 3541 , and returned to the publisher,
(2) estimated returns from news agents, and (3), copies for office use, leftovers, spoiled, and all other copies not distributed.

5. If the publication had Periodicals authorization as a general or requester publication, this Statement of Ownership, Management,
and Circulation must be published; It must be printed In any Issue In October or, If the publication Is not published during October,
the first Issue printed after October.

6. In Item 16, Indicate the date of the Issue In which this Statement of Ownership will be published.

7. Item 17 must be signed.

Failure to file or publish a statement ot ownership may lead to suspension ot Per/odocals authorization.

PS Form 3526, September 1 998 (Reverse)

Number 5

November 2000 • 1 73

Beckham Creek Cave Haven

Ever wanted to spend the night in a cave? Why not do it the luxurious way? Beckham Creek Cave Haven,
in the Buffalo National River country near Jasper, offers guests a truly unique getaway — in a living Ozark
cave. Each room at this secluded resort features natural cave walls and ceilings. The getaway has been featured
on “Lifestyles of the Rich and Famous with Robin Leach,” “NBC Nightly News,” and Home and Garden TV
and in magazines, including People, National Geographic and Four States Living.

Beckham Creek Cave features five bedrooms, each with private bathrooms with bidets. With 5,500 square
feet of living space, 10 people could share the space with plenty of room to breathe. The cave is not a bed and
breakfast, therefore guests and their family and friends have the run of the place. The cost is $300 per night,
with $75 for each additional guest. For 10 people, the cost per night is $900. Discounts are given for stays
more than one night.

The 2,000'square-foot Great Room features a natural waterfall and special lighting to help view the cave’s
stalactites. The kitchen is fit for gourmet cooking, while the game room has a pool table with a view. Even the
hot tubs in three of the bathrooms are set in natural rock formations. Horseback riding, hiking trails, swimming
and fishing are available on the cave’s 530 scenic acres. There’s even a heliport for those who want to fly in for
their vacation.

And for those who want to leave the comfort of the cave for a while, Eureka Springs is only 43 miles away,
while Fayetteville is 72 miles away and Branson, Mo., is an hour’s drive. ■

Beckham Creek Cave Haven, H C 72 Box 45, Parthenon, AR 72666. For information, call (870) 446-6045,
(888) 371-CAVE or visit www.ozarkcave.com.

1 74 • The Journal

Volume 97

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Volume 97 Number 6
December 2000

Journal

OF THE ARKANSAS MEDICAL SOCIETY

Winner of the ASAE Excellence in Communications Award

CONTENTS

FEATURES

189 Is the Big City Life Good for Everyone?

Fewer than 11% of the nation’s physicians practice in rural
areas, where the pay is smaller and the hours longer. But
small-town life offers many rewards that cannot be
measured in dollars and cents .

192 Fighting for AMS

Michael W. Mitchell has served as general counsel for
AMS for nearly 25 years . Much of his legal practice now
focuses on managed care issues that interfere with the
physician-patient relationship.

202 Serial Troponin I Measurements Detect Recurrent
Myocardial Infarction After Initial Acute Myocardial
Infarction

Dr. Elani Razek of UAMS’ department of internal
medicine and division of cardiology and two colleagues
conducted a retrospective, pilot study of serial serum cardiac
Troponin I and CK-MB measurements of 36 patients. Here,
the researchers give a report on their findings .

DEPARTMENTS

185 Commentary

Carlton Chambers, MD

187 Letters to the Editor

188 What We’ve Done
For You Lately

194 Loss Prevention
1 96 Cardiology Report

200 State Health Watch
205 People + Events
207 Membership Listing

225 Index to Advertisers

226 Arkansas Retreats

Cover Photos: Kirk Jordan

Dr. Hamilton Hart of Fayetteville
compares big-city and small-town
medical practices .

— page 189

Attorney Michael W. Mitchell defends
the interests of AMS’ members.

— page 192

Number 6

December 2000 • 181

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Be one of the first to obtain this guide, which contains
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184 • The Journal

Volume 97

COMMENTARY

"Knee-Jerk"

Carlton L. Chambers III, MD

Docs

It has occurred to me that as we move
more and more into the realm of
managed care as the mechanism for
rationing health care resources, we have
forced many (if not most) physicians to
change operating habits. A few of these
changes have been for the good, but
many are to the detriment of the
patient, and therefore to the profession.

The requirement for us to see more
patients per hour for economic reasons
is not healthy for the patient or for us.
In days long past there were times when
the physician was so overworked that
he had to short patients of their needed
time and attention. And of course there
were, and always will be, those indi-
viduals who choose to see patients too
quickly for their own pecuniary benefit.
It seems, however, that now all
physicians are forced into a pattern of
too-rapid patient care.

This rapid-fire churning of patients
often results in the type of care I refer
to as “knee-jerk” care. A typical
scenario:

After receiving a contract-man-
dated appointment within 48 hours of
calling the primary care physician’s
office, the patient arrives on time and
is presented with a stack of forms to fill
out. Halfway through completing the
oft-redundant questions she is hurried
into an exam room to comply with the
contract-required 30-minute waiting
time. Asked to disrobe and wait, she
shivers to complete the questionnaires.
After an arguably too-long wait the
harried physician arrives thumbing
through the proffered forms and gets to
hear the patient’s chief complaint
quickly followed by a couple of
questions.

A very quick inspection of the
affected part is followed by a rapid
diagnosis, and the expected prescription
is prepared. The physician leaves the

room to finish checking off the blanks
so that the computer program can type
out a beautiful form complete with
histories, complete physical exam report
and diagnostic codes, etc. This results
in a beautiful, level four, office visit
report with the appropriate charges.

This is a “knee-jerk”office visit. The
basis for the care was a very short history,
quick physical exam and a “street car”
level of diagnosis that often requires
very little of the true physician skills we
suffered through medical school to
develop.

This “knee-jerk” doctor is in stark
contrast to the physician who entertains
the patient’s history, does a proper
examination and then attempts to
educate the patient of her disorder,
recommend life changes and appro-
priate medications to enhance her life.

We as physicians have allowed the
bean-counter — and others whose
prime concern is with the accountant
rather than the patient — to dictate
to us the manner in which we will
perform our duties. In so doing we are
falling into the trap being laid for our
own demise. When patient visits can
be reduced to symptom-to-prescription
connections there will be no need for
true medical training, and we will be
replaced by nurses, technicians or
others who strongly desire to “play
doctor” without the deep respon-
sibilities taught by proper medical
training. We must resolve to keep the
best interest of each patient foremost
in our minds to honor the respect we
have been given, and to provide the
best care our patients deserve to receive.
Any less is a betrayal of our vows.

Which will you be? Physician or
“knee-jerk” doc? ■

Dr. Chambers is secretary of the AMS
and an otolaryngologist in Little Rock.

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LETTERS

INFORMATION FOR AUTHORS

Aug. 27, 2000

I am responding to Dr. Lee Abel’s
commentary, “Brilliant Disguise,” in the
September 2000 Journal. I am relating my
own experience. I believe it is a mistake to
ever present an image to another person
because you think that they expect it. It
seems many times we fall vulnerable to this
symptom of poor self-esteem.

Frankly, I suspect that many physicians,
such as myself, emerge from their scientific
training with an adolescent mindset.
Because of this, it was difficult for me to
relate in a human manner to my patients. I
had bought into the lie, as Dr. Abel
mentioned, that doctors should somehow
present themselves as powerful, symbolic
totems of healing and power. This could
not be further from the truth. Physicians
are ordinary people with all of the problems
that everyone else has. It is when we doctors
realize this and do not set ourselves apart
that we begin to really develop effective
skills as physicians.

I believe that everything I have learned
since I have been practicing medicine has
been directly learned from my patients, not
from attending seminars, spending
fellowships with experts and reading
scientific literature. Medicine is an art and
always will be an art. Communication is
impossible if there is a lack of a certain
amount of bonding between the patient and
the physician. This may sound trendy, but I
do believe that there is a certain amount of
intimacy involved that many physicians fear

Sept. 1, 2000

This is written in response to the
conclusion written by J. Kelley Avery, MD,
in the Loss Prevention article, “A Baseline
is Necessary,” from the September 2000
issue.

In a nutshell, an otherwise healthy 42-
year-old woman with stress incontinence
and uterine prolapse was treated with a
routine vaginal hysterectomy and anterior
and posterior repair. Postoperatively she
was given between 5 and 6 liters of D5 W
(the article doesn’t say how long a period
of time was required to give this solution) .
The patient ended up dying apparently
from “water intoxication resulting in
severe hyponatremia.” Dr. Avery
concludes with the implication that what
killed this lady was the surgeon’s failure
to obtain a preoperative electrolyte study.
That conclusion is absurd. The problem
here is that this poor lady was poisoned with
water. I don’t see how a preoperative
electrolyte study would have made any

to face because of the persistence of their
emotional immaturity which began in the
cloistered environment of medical school.
If your fear or ego blocks your ability to have
no mask, then I feel sorry for you.

1 believe that a physician’s professional
talents, skills, intuition and art are definitely
on loan, so there is no need for a doctor to
feel proud of his accomplishments but grate-
ful for the opportunity to offer service. I do
feel that medicine is a vocation just like the
ministry, so look upon a career in medicine
as an ego massage, and a self-retirement is to
sell oneself short, and in effect spoil, the whole
opportunity to be of real use to your fellows
who suffer from disease.

Money has corrupted medicine, and the
people in medicine, just like it, corrupts
people in business and other professions.
Money has no value. It has evidence of value,
hut essentially it is worthless except as a
medium of exchange for material items.

Finally, Dr. Abel, if you really want to
clean some dishes, put Credence Clearwater
Revival on instead of Bruce Springsteen.
Thanks for your provocative commentary
and for stimulating me to think about this
subject, which I feel is critical for our
profession to grasp before we sell ourselves
short without realizing what an opportunity
we have to do good. ■

Sincerely,

Joseph W. Matthews , MD
Little Rock

difference in light of the type and amount
of fluids she was given.

In my orthopaedic practice, we have a
loose protocol developed in conjunction
with the anesthesiology department
regarding preoperative testing. Routine
electrolyte studies in a healthy 42-year-old
woman are not required in our protocol nor
are they needed. I don’t think they were
needed in the case described in the article.
What was needed was an appropriate type
and amount of postoperative IV fluid.
Unless fluid and electrolyte physiology is
drastically different in an OB/GYN patient
from what it is in an orthopaedic patient,
malpractice was committed here. I don’t
really think there’s much of a loss
prevention lesson in this article. What we
have here is a doctor who needs to go back
to medical school. ■

Sincerely,

Scott S. Cooper, MD
Rogers

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Number 6

December 2000 • 187

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WHAT WE’VE DONE FOR YOU LATELY

Behind-the-Scenes
Legal Work Provided
to AMS Members

By David Wroten

Let’s face it: We all know a few good, or not so good, lawyer jokes. In this
month’s issue of The Journal, we are featuring an attorney for whom I
have a great fondness, so I’m resisting the urge to begin this article with
a few classics.

Michael Mitchell is the legal counsel for the Arkansas Medical Society.
Most of the physicians who make up AMS have never met Mike, and most
never will meet him. Those same physicians have most likely benefited
from his legal knowledge even though they probably don’t know in what
way.

If you’ve ever called the Society for a legal question related to your
practice, you probably have received a response from me, Ken LaMastus or
maybe Lynn Zeno. Maybe it’s a question about medical records, dismissing
an unruly patient, managed care contract issues, patient confidentiality,
compliance with the Americans with Disabilities Act or a host of other
medical issues. The advice you received was most likely given only after
careful discussion with Mike Mitchell.

Mike is one of only a handful of attorneys in Arkansas who have
developed a certain specialization in medical issues. We put that knowledge
to good use where it directly and indirectly benefits you. If you treat
Medicaid patients, you have directly benefited from a 1992 lawsuit over
Medicaid reimbursement. Mike and his associate, David Ivers, now one of
Mike’s partners, successfully tried what was to become a landmark case.

The AMS’ Physician’s Legal Guide, now in its second edition, was
developed and written exclusively by Mike’s law firm. It is the only
publication of its kind for Arkansas physicians and one that every medical
practice should own.

Like many attorneys, Mike is a lobbyist and a key player in AMS
legislative affairs efforts. Working closely with Lynn Zeno, our director of
governmental affairs, Mike plays a major role in our lobbying activities, and
his firm routinely drafts language for our legislative and regulatory
proposals, such as the Health Care Consumer Act and Patient Protection
Act.

As a private attorney, Mike is obviously not an AMS employee. We do,
however, consider him a member of our AMS family and a trusted friend
and adviser to our staff, officers and membership. From Mike, you get more
than legal advice, more than someone to write or review contracts. I have
witnessed firsthand the respect and admiration Mike has for physicians and
their patients.

As an AMS member, I thought you should know a little more about
Mike and how he benefits your practice and your profession. It’s not what
have we done for you lately, but what your association does for you each
day with the help of people like Mike Mitchell.

We’re proud to feature Mike in this month’s issue of The Journal of the
Arkansas Medical Society. ■

188 • The Journal

Volume 97

Big City Life Good for Everyone?

Many Arkansas physicians choose to practice
in rural America, where the pay is smaller,
the hours longer and life is more care-free.

By Christy L. Smith

Dr. Charles Jackson has never received chickens as
payment for services, but his patients often bring
him jams, vegetables they’ve grown in their gardens
and fishing lures to show their appreciation for his work.

“That happens pretty often in a small town. It’s nice, really,”
he said.

The 31 -year-old family physician has practiced at St.
Joseph’s Medical Clinic in Mount Ida, population 930, for three
years. He said living in a large city has never been an option for
him and his wife, both of whom grew up in small towns.

Living in a small town allows Dr. Jackson to fish, farm,
garden and tend cattle, plus it offers a
better atmosphere in which to raise his
three children — Andy 6, Matthew, 4, and
Rusty 18 months.

“That’s part of why I ended up in this
area,” he said. “When I went through
medical school and did my residency, I
knew that we were both from smaller
areas and don’t like big cities. Where I
live now, I’m eight miles from my office.

When I drive to my office, 1 can count
the number of cars I see on one hand.

On a busy morning, you can count them
on two.”

But Dr. Jackson is in the minority.

According to the National Rural Health
Association, based in Kansas City, Mo.,
fewer than 11% of the nation’s physicians practice in rural
areas. The approximately 5 1 million Americans living in rural
areas are in need of health care because they tend to have
higher rates of poverty and infant mortality, as well as a denser

concentration of elderly patients, than urban residents,
according to the association.

“Medical students are discouraged in both subtle and
overt ways from entering primary care specialties and from
practicing in underserved areas,” Drs. Debra M. Phillips of
Illinois and Philip G. Dunlap of Massachusetts pointed out
in a November 1998 association issue paper, “Physician
Recruitment and Retention.” Less pay, longer working hours
and fewer job prospects for spouses accompanying
physicians to rural areas are just a few of the reasons
physicians do not set up practice in rural areas, said Drs.
Phillips and Dunlap.

Dr. Jackson agreed it’s hard to
recruit physicians to rural areas. He has
been the only doctor practicing at the
two-man St. Joseph’s Mount Ida Medical
Clinic for two years. One entire wing of
the clinic stands unused, he said.

“We’ve had five or six doctors come
here and then go to another place like
Mena. One thing that probably deters
doctors from practicing in a small town
is that you can make more money in a
larger city. There’s no doubt about it.
There’s a big difference financially,” he
said.

But Dr. Jackson said he wouldn’t
trade his small-town life for the hubbub
of a big city, even though he works long hours and cannot
hide from his patients.

“Here, you can’t avoid patients. People know where I
live. People call me at home. They show up on my front

Charles Jackson, MD

Number 6

December 2000 • 189

steps. 1 can’t go anywhere without
seeing somebody I know. I can’t think
of a single place where I can go hide
here. But we like the lifestyle a small
town offers,” he said.

Fleeing Rural America

Dr. William E Joseph, who hails from
the 4,300-person Walnut Ridge, grew up
the son of a small-
town doctor. The
44-year-old family
practice physician
said he remembers
well the disappoint-
ment of sharing his
father with patients
during family times.

“It was not un-
common for us to
be eating supper,
and a patient would
come to the house,”
he said. “I remember
one Christmas mor-
ning when he had to
go to the hospital.

We couldn’t even
complete opening our Christmas gifts.”

The Joseph family eventually began
excepting those incidents without ques-
tion, and oftentimes postponed their
holiday celebrations until the family
patriarch returned from his call, Dr.
Joseph said.

“We didn’t question it. He just went
upstairs and came back down dressed,
and my mother said, ‘Kids, daddy has to
go to the hospital. Let’s play with these
toys and when he gets back, we’ll see
what else Santa Claus brought,”’ he said.

But that’s the kind of life Dr. Joseph
said he did not want for his four
children — Eric, 13, Zack, 11, Alex, 4,
and Lauren, 2. So, after finishing his
residency in 1985, Dr. Joseph established
his practice at St. Vincent Family Clinic
in Little Rock.

“This affords me the opportunity to
have a high-quality practice with
technology. 1 can provide high quality for
my patients and have a very stimulating
professional environment, but yet at the
end of the day when I go home, I get to
be a husband and a father and do the
things that small-town doctors don’t have
the luxury of doing,” he said.

According to the Federal Office of
Rural Health Policy, physicians in small
towns spend as much as 16% more time
per week in direct patient care and have
38% more patient visits per week than
their metropolitan counterparts.

Dr. Joseph said he sees 25-30
patients per day, works a normal, eight-
hour day four days each week, and has
no hospital duty.

But Dr. Richard
Davis, a 43-year-old fam-
ily practice physician at
the Smackover Family
Practice Clinic, generally
works a 14- 16-hour day,
seven days a week. Plus,
since he’s the only prac-
ticing physician in Smack-
over, Dr. Davis is not
immune to occasional
drop-ins at his home, he
said.

“One of the unique
things about being in a
small town is if some-
body’s having an acute
problem, they’ll come
by my house to get me,” Dr. Davis said.
“If I don’t see those people, there’s no one
else in the community who can handle
medical problems. In small-town
medicine, you are on the front line. A lot
of times you have to handle some
problems rather acutely in the clinic until
you can get that person stabilized to get
them to the specialty care they need.”

Originally from North Little Rock,
Dr. Davis said he moved to a small
town 15 years ago because the envir-
onment is more conducive to raising a
family. Smackover was especially
appealing because of its proximity to a
larger town, El Dorado, which is only
20 miles away.

“I was looking for a smaller town
closer to a large town so that I could be
involved in a large-town call schedule,”
he said.

Rural Medicine Benefits

Practicing medicine in a rural area
has its own unique set of features.

More than 5 1 million Americans live
outside metropolitan areas, defined by
the U.S. Office of Management and Bud-
get as a community of at least 50,000

William Joseph, MD

residents, according to the National
Rural Health Association.

Those rural residents tend to be
“older, poorer, sicker, less educated”
than their urban counterparts,
according to the association. Plus, rural
residents have a higher rate of infant and
injury-related mortality, fewer hospital
beds and are less likely than urban
residents to have health insurance.

Dr. Davis concedes managed care
hasn’t caused much of a stir in rural
south Arkansas.

“South Arkansas doesn’t have a large
amount of managed care. It hasn’t hit
us as hard as other places. The majority
of patients are fee-for-service,” he said.

That’s because rural communities
lack the economic base to support large
employers, who are more likely than
small businesses to provide their
employees with health coverage, said
Dr. Hamilton Hart of Fayetteville.

“Managed care is a product of an
employer, and if you are self-employed
in a rural area, you are not going to
have managed care available to you,”
said the 59-year-old family practice
physician.

During the 1960s, Dr. Hart was
stationed at Memphis in the Navy. He
said that during his stint in the military,
he “moonlighted” at a clinic in Forrest
City, a small city of about 13,000. Since
establishing his practice in Fayetteville,
population 58,163, in 1971, he has
witnessed firsthand the affect managed
care can have on the well-being of
patients, he said.

“Managed care probably has
resulted in a lot of people getting better
care,” Dr. Hart said.

Patients have better screening for
cancer and cardiac disease, monitoring
for conditions such as diabetes and
high blood pressure, and many patients
have stopped smoking due to managed
care’s emphasis on smoking cessation,
Dr. Hart said.

And managed care has promoted
“continuity of service” by requiring the
enrollee to choose a primary care
physician, he said.

But there’s no doubt that managed
care is burdensome, said Dr. Joseph.

“In a more urban area, we are
inundated with managed care,

190 ® The Journal

Volume 97

formularies, things that increase the
hassle factor. That’s one thing that our
compadres in small towns are not
having to deal with to the degree that
we are,” he said.

Although practice styles differ in
rural and urban settings, doctors in both
areas deal with the same basic illnesses,
Dr. Joseph said.

“We take care of the same types of
problems that small town doctors do —
bread-and-butter things like hyper-
tension, diabetes, depression, upper
respiratory infections,” he said.

But access to care is a problem for
many rural residents, Dr. Joseph said.

“In some of the rural areas, there’s not
the access to medical care that we have in
a metropolitan area. You tend to see more
in-stage problems that could have been
prevented if those patients could have
afforded medical care. In metropolitan
areas, there tend to be more social-service
resources available,” he said.

Small-town doctors also tend to see
more elderly patients than their big-city
counterparts because they are juggling
their clinic-based practices with nursing
home and hospital work, he said.

“They don’t have the luxury of
having someone take care of their
hospital patients for them,” Dr. Joseph
said.

But the lack of managed care,
technology and specialist support in
rural areas means that doctors
practicing there have the oppor-
tunity to make a true difference in
the lives of their patients. Dr. Davis
said.

“In a small town, you are so
close to your patients,” Dr. Davis said.
“You know them personally, you
know their families. When they are
going through difficult times, you are
going through difficult times, too. It’s
easier to feel the compassion you need
to feel toward your patients when it’s a
personal friend.”

Dr. Joseph said the thought of
giving up that physician-patient
closeness nagged at him when he was
trying to decide whether to establish his
practice in Little Rock.

“That was a real difficult decision
because I role-modeled after my father.
There’s no question from a quality-of-
life standpoint, if you like small towns,
that’s a fabulous way to give back to
the community. It’s a fabulous way to
feel like you are an intimate part of the
lives of your patients,” he said. ■

A Different Lifestyle

Physicians who practice in rural
areas often develop close-knit rela-
tionships with the people in their
communities, but the trade-off is that
they tend to work without a strong
network of specialist support, according
to the National Rural Health Association.

And that’s a trade-off Dr. Joseph was
not willing to make, he said.

“The small-town communities are
very homey, and you really feel like you’re
making a difference. In a city like Little
Rock, you have anonymity and really
very little influence. That same individual
in a small town would be very active on
the school board and in their church and
in a variety of other areas. You’re
dramatically diluted down in the city. I
miss the Friday night football games at
Walnut Ridge High School, but it’s just a
trade-off,” he said.

The lack of
specialty support
can be very taxing
on a small-town
physician who must
handle all manner =

•p

of emergencies and -e
illnesses on his own, *

Dr. Hart added. I

“It’s very, very
difficult to be everything to everyone, and
the long hours and lack of sleep sometimes
wear them down,” he said.

Dr. Hart said when he began his prac-
tice in 1971, Fayetteville had only 25,000
people, five family practice physicians and
five specialists. Today, the city has more
than doubled in size, and there are more
physicians and specialists than he can
count.

“I’ve had so much help from all the
specialists in town,” Dr. Hart said. “Before,

I had to handle pretty much everything
by myself. It has made our lives so much
easier. It’s so much nicer to come to
work feeling rested and feeling like you
can function better. It’s really the ideal
way to practice — having somebody to
help you.”

Recruiting
for Rural
Arkansas

The Community Match Student Loan
and Scholarship Program was created by
the Arkansas Legislature in 1995 to
increase the number of primary care
physicians in rural Arkansas.

Under the Community Match
Program, qualified medical students at
the University of Arkansas for Medical
Sciences are paired with rural communi-
ties in need of a primary care physician.

The community pays up

Medical to $16,500 per academic

year to help students
Student complete their medical

program studies. and in exchange

the students promises to
is a win* practice full-time

Win for primary care medicine in

the contracting

everyone community for the same

number of years they
received financial assistance.

According to the guidelines of the
match program, a rural community is one
with a population of less than 15,000, or
one that has been deemed to be a “health
professions shortage area" by the state
Rural Medical Practice Student Loan and
Scholarship Board. Forty-eight Arkansas
communities have participated in the
program since 1995. Among them are
Corning, Piggott, Forrest City, Helena,
Dermott, Magnolia, Mineral Springs,
England, Perryville, Clinton and Harrison.

To date, about 70 UAMS graduates have
been placed in rural communities through the
match program, said Yvonne Lewis,
associate director of education for the state
Area Health Education Centers program.

The program hit a peek in 1998-99,
when 23 medical school graduates were
placed. Thirteen graduates participated in
the 2000-2001 Community Match
Program.

According to program guidelines,
loan and scholarship recipients must be
residents of Arkansas who are enrolled in a
“medically underserved and rural practice
curriculum” at UAMS; be a person of
“good moral character” and possess the
“talent and capacity to profit” from his
medical studies; and be approved by a
designated representative of a qualified
rural community. Each student applicant is
interviewed by the Rural Medical Practice
Student Loan and Scholarship Board. ■

Number 6

December 2000 • 191

Meet Our Attorney

Michael W. Mitchell

By Christy L. Smith

Arkansas physicians have a friend in Michael W.
Mitchell.

As general counsel for the Arkansas Medical Society,
the 56'year'old attorney intervenes any time a third party
threatens or interferes with the physician-patient relationship
in Arkansas. He has written letters, filed lawsuits and
attended regulatory hearings on behalf of the medical society.

“I’ve been called upon to do everything except ... sweep
the floor,” he said, joking.

Mitchell’s law firm, Mitchell, Blackstock and Barnes of
Little Rock, has represented the medical society for nearly
25 years, and recent changes in the medical field have
fundamentally altered the nature of his work. While scope-
of-practice issues occupied much of his time
when he started representing AMS,
managed care is Mitchell’s No. 1 priority

Medical

Society

Attorney

Takes on

Managed

Care

now.

“With a client such as the medical
society, you’re going to, by necessity, do a
lot of continuing legal education in the area
of health care law,” he said.

Mitchell, the only son of four
children, spent the first decade of his
life in Pine Bluff. His family moved
to Tyler, Texas, in the mid-1950s
when his father, a Cotton Belt
Railroad employee, was trans-
ferred to company headquarters.

Mitchell graduated from the University of Texas
at Austin in 1966. He pursued a career in law at the
urging of his father.

“He sized my personality up ... and felt
like [law] was what I should do. So, I did
it. Fortunately, he was right,” Mitchell
said.

He graduated from the School of Law
at the University of Arkansas at
Fayetteville in 1969 and immediately started
a practice in Pine Bluff. Six years later, Mitchell
partnered with some of his law school buddies

in Little Rock. That firm soon merged with a practice begun
by “sage, venerable, mentoring lawyers” Eugene R. Warren
and Judge Brooks Bullion, who had long since retired from
the bench, Mitchell said.

Mitchell initially worked alongside Warren, repre-
senting AMS. He took over as general counsel in 1980 after
Warren’s death.

The issues Mitchell dealt with 20 years ago — Good
Samaritan statutes, physician liability, medical malpractice
and scope of practice — have given way to managed care
problems such as physicians’ rights, contractual matters and
legislative issues, Mitchell said.

“Many things these days attack the physician-patient
relationship, which is the core of what doctors do. Rather
than the physician and the patient making decisions in
the best interest of the patient, a third party has now inter-
ceded,” Mitchell said.

And in some cases, third-
party intervention can
severely hinder a phy-
sician’s ability to remain
in practice, Mitchell said.

When he is not addressing managed care
issues for Arkansas physicians ,

Michael W. Mitchell enjoys
spending time outdoors with his
son, Michael Charles, 13.

192 • The Journal

For instance, while the common consumer is expected
to remit payment for a bill within 30 days, some insurance
companies take as long as 1 20 days to pay a physician for his
services, Mitchell said.

“They seem to have the power of the purse. They make
the rules on when they pay. We recently
had an issue before the Insurance
Commission [questioning] the length of
time that is proper for an insurance
company to pay an acceptable claim,”

Mitchell said.

That issue has yet to be resolved.

“These things aren’t resolved in a matter
of days or even weeks. They are ongoing,”
he said.

It also is not uncommon for third-party
providers to drop a physician from their
plans when that physician encourages his
patients to vigorously request that
coverage be extended to treatments that are considered
experimental, Mitchell said.

“Contractual issues between physicians and insurance
companies are becoming more of an issue. Generally,
Arkansas has always been an at-will employment state. So,
can an insurance company for no reason cast aside a physician
who is doing a good job [when he] advocates for patients to
call and make a lot of noise about providing coverage?

“The insurance company gets irritated at this doctor
because they don’t want to hear the complaints, so they
terminate his contract. The physician cannot see those
patients anymore. They may have a huge percentage of his
patients, so it could literally in one day affect his practice
severely,” he said.

Mitchell predicted this type of
contractual dispute would continue to be
a problem as managed care evolves. He
said bills dealing with what he called the
unfair practices of managed care entities
would be debated in the state Legislature
until the system was changed.

“The evolutionary process is slow, and,
hopefully, [one day] we can look back and
say that we have some sort of animal that’s
fairer to the doctor, fairer to the patient and
fairer to the insurance company. You have
those three interests that have to be
balanced,” he said.

When he is not dealing with managed care and the
many tasks assigned to him by the medical society, Mitchell
enjoys snow skiing and mountain biking. In fact, the lawyer
sets aside one week every year to enjoy Colorado’s great
outdoors with six to eight of his closest friends.

Mitchell is married and has two children. His wife, Mary,
is a medical social worker. ■

"Contractual issues
between physicians
and insurance
companies are
becoming more of
an issue. "

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Number 6

December 2000 • 193

LOSS PREVENTION

Learn From and Respond
to the Medical Record

J. Kelley Avery, MD

The patient was a 30-year-old woman who
came to her obstetrician during the first
trimester of her third pregnancy. With the first
pregnancy the patient had a spontaneous
abortion. Her second pregnancy, attended by
the same obstetrician, ultimately resulted in a
healthy haby, but during the prenatal period the
patient was found to have gestational diabetes,
and although the baby was healthy, the mother
had a hard labor and a difficult delivery. There
was moderate to severe shoulder dystocia and
the Apgar scores were low (4 and 8). The
newborn was successfully resuscitated, but this
should have alerted the doctor to the possibility
of a small pelvis in his patient.

Six months before her first prenatal visit she
was seen for a routine check-up. The record
indicated, “Normal Gyn examination. Pelvic
pain and return in a year unless pain worsens.”
There is no further documentation of findings
on this annual check-up.

On the first prenatal visit the good,
complete physical examination within normal
limits. The LMP was recorded as June 15, and
the EDC was estimated as March 22. Her blood
pressure was 126/80 mm Hg and weight 168
pounds. All the laboratory data were normal.
The previous history of gestational diabetes
was recorded, and the 24-hour labor with
shoulder dystocia was made a part of this
prenatal record. Three months later an
ultrasound caused the physician to update the
EDC to March 16. A fasting blood sugar was
89 mg/dl, and three hours after receiving 50 gm
of glucose her blood sugar was 144 mg/dl. A
week later the test was repeated, with
essentially normal results. On that occasion
100 gm of glucose was given, and the three-
hour blood sugar was 129 mg/dl. The patient
was told that her glucose tolerance test was
normal.

At about 27 weeks gestation her urine sugar
was reported as 3+, and about three weeks later
another GTT was done. On this occasion the
fasting blood sugar was 89 mg/dl but after lOOgm
of glucose, the one-hour value was 186 mg/dl,

the two-hour value 181 gm/dl, and the three-
hour value 92 mg/dl.

The patient gained about 30 pounds during
the pregnancy, and at about 38 weeks the
obstetrician recommended that labor be
induced. She was admitted to the hospital in
the early morning for induction, and the
routine orders were given. The fetal heart rate
(FHR) was recorded in the 140 range when
the Pitocin drip was begun. In the first hour of
Pitocin induction the FHR was recorded in the
130s. A fairly aggressive increase in the amount
of Pitocin was a part of the protocol. When
the physician was contacted, he examined his
patient promptly, affirming the increase in
Pitocin. About three hours after induction was
begun, the FHR was recorded in the range of
120-130/min.

Eight hours into the induction the head
was still high and the membranes intact. An
attempt was made to rupture the BOW through
a cervix dilatated to 1-2 cm, but it was
unsuccessful. The Pitocin drip was pro-
gressively increased per protocol or direct
orders, and 12 hours into the induction the
FHR was recorded at 1 10-130/min. The cervix
at this time was 4-cm dilated, but the head
was not in the pelvis. The position was recorded
at -2.

About 18 hours after the onset of
induction, an epidural anesthetic was given,
relieving the patient’s pain somewhat. An hour
later the first late deceleration of the FHR was
noted. When the doctor was notified, the
Pitocin was reduced for about 30 minutes.
Within an hour, further late decelerations were
noted, this time below 100/min. These findings
on the electronic fetal monitor (EFM)
continued and were reported to the doctor. On
change of position, they would seem to improve
but continued to be reported by the staff.

Twenty hours after admission to the labor
and delivery suite, the obstetrician took the
patient into the delivery room and attempted
a forceps rotation and vacuum extraction,
both of which were unsuccessful. With the

194 • The Journal

Volume 97

EFM continuing to show decelerations,
the patient was prepared for Cesarean
section (C-section), a laceration of the
perineum was noted, and it was repaired
before the C-section was begun.

A male infant weighing 10 pounds,
10 ounces was delivered, with Apgar
scores of 1-4 and 5. He was put in the
care of a neonatologist and taken to the
neonatal intensive care unit. He had
respiratory problems requiring ventilator
support for about two weeks, and seizures
in the first 1 2 hours. He appeared to be
quadriplegic, and was discharged from
the hospital with a diagnosis of hypoxic
encephalopathy. He died at about 18
months of age.

The obstetrician was charged with
negligence in ( 1 ) failing to detennine the
condition of the mother and child before
inducing labor, (2) failing to obtain
informed consent for the elective
induction of labor, (3) electively inducing
labor and (4) failure to respond
appropriately to signs of fetal distress and
failing to do the C-section in a timely
manner. A very large settlement was
required to settle this case.

Loss Prevention Comments

Medical malpractice cases are not
lost because of errors in judgment. They
are lost when the judgment errors do not
follow careful use of all the data available,
and the case is not handled in a logical
and sound fashion based on the
information the physician has. The
attending obstetrician had delivered a
baby for the patient two years earlier. He
had recorded in the hospital record that
the mother was a gestational diabetic and
that she had a difficult labor due to
shoulder dystocia even though the baby
weighed only 7 pounds, 6 ounces.

He had not documented this
previous experience in the prenatal
record of the patient with this pregnancy.
He had acted upon that memory hy
doing the appropriate tests for ges-
tational diabetes. On at least one of these
glucose tolerance determinations,
hyperglycemia was unmistakable,
indicating gestational diabetes. She had
gained about 30 pounds during the
course of the pregnancy, and urine

specimens had been checked regularly
for glucose. Toward the end of the
prenatal period the urine was con-
sistently glucose-positive. Ultrasound
examinations had been done at expected
intervals, and the condition of the baby
had been determined to be normal, but
nowhere in the record does the estimated
weight appear.

Based on the physician’s knowledge
of the gestational diabetes and
possibility of a macrosomic baby, the
decision was apparently made to induce
labor at about 38-39 weeks gestation,
and the patient was admitted for this
purpose at about 7 a.m.

There was no documentation of
discussion with this patient about
inducing labor. One presumes, giving
the attending physician the benefit of
the doubt, that such a discussion did
take place. Perhaps the prior delivery
and the difficulty she experienced with
the shoulder dystocia was discussed, but
we had no record of that either. The
standard orders for induction were
given and the protocol indicated by
those orders was begun.

Examination revealed that the fetal
head was not in the pelvis, and the
cervix was not dilated. From the record,
true labor did not start until about 2
p.m. Slow progress was made, even with
regular increases in the amount of
Pitocin given. It was about 5 p.m. when
the patient began to require increased
amounts of pain medication, and about
two hours later an epidural anesthetic
was given.

About 9 p.m. the nurses reported
some late decelerations on the EFM.
The obstetrician examined his patient
and apparently was reassured by the
tracing that no real problem with the
fetus was developing, and the in-
duction proceeded with increasing
amounts of Pitocin. There was no
physician’s note on the chart or the
EFM tracing to indicate his assessment
or plan. Again, at about 10 p.m. the
nurses reported decelerations to a FHR
of “below 130,” falling, hut not critical.
The physician examined his patient,
and noted in the record that the
findings were subtle and inconsistent,

hut stimulation with Pitocin con-
tinued. On a thorough review, a
qualified expert believed that at this
point the baby was healthy.

After midnight, decelerations
continued, the FHR falling to the range
of 100/min and accelerations at and
above 160/min. The increases in
Pitocin continued according to orders.
This judgment is certainly questionable
in the face of the tracing and the FHR.

When at about 3:30 a.m. the decel-
erations with pushing showed rates in
the 80s, lasting for 30 seconds or more,
the patient was taken to the delivery
room for an attempt at vacuum de-
livery. It failed, as did forceps rotation
of the head. A laceration of the
perineum was discovered, and even
with the FHR at 60-80/min and with
decreasing variability of the heart
monitor, repair was done before the C-
section was begun. Again, this was
considered an error in judgment, and
below an acceptable standard of care
based on available data.

There were consistent deviations
from an acceptable standard of care
for at least three hours before delivery.
This patient had had a hard labor
previously with a 7 pound, 10 ounce-
baby. Additionally, she had had with
her previous pregnancy, and this one,
gestational diabetes. The obstetrician
gambled with his patient far too long
in the attempt to achieve a vaginal
delivery. He was attentive to his
patient, came when called by the nurses,
but certainly did not take into account
all the facts available to him, and failed
to do a timely C-section. Had he done
so, this baby would have had a good
chance of being born without the
devastating neurologic damage that
took his life at 18 months of age. ■

Reprinted from a September 1 999
issue of Tennessee Medicine. The Case
of the Month is taken from actual
Tennessee closed claims. An attempt is
made to fictionalize the material in order
to make it less easy to identify. If you
recognize your own case, please be assured
that it is presented solely for the purpose of
emphasizing the issues presented.

Number 6

December 2000 • 195

The Role of Amiodarone in the Management
of Patients with Cardiac Arrest

Amy M. Franks, Pharm. D. candidate — Krista Sue Watterson, Pharm. D.

EDITOR: Eugene S. Smith, III, MD

The standard format for this section has changed this month
to consider the new American Heart Association guidelines for
the treatment of ventricular tachycardia and cardiac arrest. One
of the more important changes involves the recommendation of
amiodarone as the primary antiarrhythmic agent. Such a change
pushes amiodarone from the domain of the cardiac specialist into
the standard armamentarium of the general physician. The
following describes the rationale for such a move and equips the
practitioner for using this agent in the appropriate settings.

Antiarrhythmic drug therapy is commonly used in the
treatment of patients in cardiac arrest due to ventricular fibrillation
refractory to electrical defibrillation. The 1992 American Heart
Association Advanced Cardiac Life Support ( ACLS) guidelines
recommended lidocaine be used as the first antiarrhythmic drug
after electrical defibrillation and epinephrine administration.1
However, the American Heart Association recognized that there
is limited evidence from randomized controlled trials to support
the routine use of lidocaine in the treatment of ventricular
fibrillation. Most early studies of lidocaine use were limited by
flaws in study design and the use of animal models.2,3

Since the 1992 ACLS guidelines were published, amiodarone
(Cordarone®) has become available in an intravenous
fonnulation. Amiodarone is a Vaughan
Williams Class III antiarrhythmic agent
with a complex mechanism of action.

This agent predominantly exerts its
antiarrhythmic effect by blocking
potassium channels and thereby pro-
longing myocardial refractoriness. 1 5
Amiodarone ’s clinical effectiveness was
recently evaluated in the Amiodarone for
Resuscitation After Out-of-Hospital
Cardiac Arrest due to Ventricular Fib-
rillation (ARREST) trial. This trial was
a randomized placebo-controlled study
that investigated the administration of
amiodarone for the treatment of out-of-
hospital cardiac arrest due to ventricular
fibrillation (VF)/pulseless ventricular

tachycardia (VT). In this study, 504 adult patients who failed
electrical defibrillation of VL/pulseless VT were randomly assigned
to receive placebo or intravenous amiodarone. The study’s primary
endpoint was survival-to-hospital admission with a stable,
organized rhythm. Compared to placebo, amiodarone therapy
resulted in a statistically significant higher survival-to-admission
rate (34% vs. 44%, respectively, a relative increase in survival of
29%; P=0.03). Therefore, the addition of amiodarone to ACLS
procedures resulted in the survival-to-admission of an additional
one out of 10 patients treated for VL/pulseless VT. However, there
was not a significant difference in survival-to-hospital discharge
between the amiodarone group and the placebo group ( 1 3 .4% vs.
13.2%, respectively). The authors stated the study was not
designed to determine differences in the survival-to-discharge.
Further studies are necessary to determine long-term survival rates
after treatment with amiodarone for VF.6

Based in part on the evidence from the ARREST trial, the
American Heart Association has modified its recommen-
dations on the pharmacological treatment of cardiac arrest due
to VL/pulseless VT. The Guidelines 2000 for Cardiopulmonary
Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
are the first recommendations based on international consensus.

Table. Classification of Therapeutic Interventions*

CLASSES INTERPRETATIONS EXAMPLES

Class 1

• Excellent evidence of effectiveness

• Definitely recommended

Electrical defibrillation for
VF/pulseless VT

Class II a
Class II b

• Good evidence to support intervention

• Acceptable intervention

• Probably a useful intervention

• Fair evidence to support intervention

• Acceptable intervention

• Possibly a useful intervention

Sodium bicarbonate use
in tricyclic antidepressant
overdose

Amiodarone for shock
refractory VF/pulseless VT

Class

Indeterminate

• Evidence is insufficient to support
recommendation

• Acceptable but not recommended
intervention

Lidocaine for shock
refractory VF/pulseless VT

Class III

• Beneficial evidence is absent

• Evidence suggests or confirms harm

• Unacceptable intervention

Sodium bicarbonate use
in patients with
hypercarbic acidosis

‘Adapted from reference 7. VF = ventricular fibrillation, VT = ventricular tachycardia

196 • The Journal

Volume 97

These new guidelines place increased
emphasis on evidence from randomized
controlled trials. As in the 1992 ACLS
guidelines, the initial treatment of VF
places emphasis on the rapid application
of CPR, electrical defibrillation and airway
management.1 As before, antiarrhythmic
drug therapy may be utilized for VF that is

Figure. Algorithm for
Ventricular Fibrillation/Pulseless
Ventricular Tachycardia*

(assume that ventricular fibrillation /
pulseless ventricular tachycardia persists
after each intervention)

Consider antiarrhythmic intervention:

Amiodarone 300 mg IV push as a one
time single dose (Class II b). If VF/
pulseless VT recurs, consider admin-
istration of a second 1 50 mg IV dose.
Maximum cumulative dose: 2.2 g over
24 hours.

Lidocaine I to 1 .5 mg/kg IV push (Class
Indeterminate). Consider repeat in 3-5
minutes to a maximum cumulative dose
of 3 mg/kg. A single dose of 1 .5 mg/kg
in cardiac arrest is acceptable.
Magnesium 1-2 g IV in polymorphic VT
(torsades de pointes) and suspected
hypomagnesemic state.

Procainamide 30 mg/min in refractory
VF (maximum total dose: 1 7 mg/kg) is
acceptable but not recommended
because prolonged administration time
is unsuitable for cardiac arrest.

Consider buffers

Resume attempts to defibrillate

Use 360 J (or equivalent biphasic) shocks
after each medication or after each
minute of CPR. Acceptable patterns:
CPR-drug-shock (repeat) or CPR-drug-
shock-shock-shock (repeat).

‘Adapted from reference 7. VF - ventricular
fibrillation, VT = ventricular tachycardia, J = Joules,
IV = intravenous, CPR = Cardiopulmonary
Resuscitation.

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Number 6

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refractory to electrical defibrillation. The
new guidelines have modified the recom-
mendations for the use of pharmacological
agents in resuscitation. One major change
in the Guidelines 2000 is the recommen-
ded use of amiodarone in place of lidocaine
as first-line drug therapy of VF/pulseless
VT.7 (See Figure for the new VF treatment
algorithm.)

In the new guidelines, the recommen-
dations for pharmacological management
are evidence-based and classified by the
strength of evidence supporting its use
(Table). The treatment of VF with
lidocaine was given the newly defined
Class Indeterminate recommendation. By
definition, Class Indeterminate recommen-
dations can still be recommended for use,
but practitioners are reminded that
evidence is limited to study results that may
be inconsistent, contradictory or may fail
to address relevant clinical outcomes.
Conversely, amiodarone has been assigned
a Class lib recommendation for its use in
refractory VF. Class lib interventions are
considered “within the ‘standard of care.’”7

The Guidelines 2000 recommend
amiodarone be administered as a single bolus
infusion of 300 mg for the treatment of VF.
The intravenous formulation of amiodarone
is supplied as a concentrated solution in a
glass ampule. The contents of the ampule
should be diluted with saline or dextrose in
water and rapidly injected into a peripheral
vein.7 Amiodarone can be safely admin-
istered undiluted (E.R. Gonzalez, oral
communication, September 2000).

Other than effectiveness, amiodarone
has significant advantages over other anti-
arrhythmic drugs, including a simple load-
ing regimen. Amiodarone is given as a single
bolus dose as opposed to the more complex
administration of other antiarrhythmic
agents. This bolus dose is not based on
patient weight, but simply a standard 300
mg dose.7 Amiodarone appears to have few
significant short-term cardiovascular
adverse effects.4 As shown in the ARREST
trial, hypotension and bradycardia that
occurred with amiodarone administration
were easily treated with intravenous fluids
and inotropic or chronotropic support.6

From an administration standpoint,
amiodarone is not currently available in a
prefilled syringe due to its adherence to
plastic surfaces. However, amiodarone may
be administered in plastic infusion devices
when infusion time does not exceed two
hours.8 While there is no pharmaco-
economic analysis available, the acquisition

198 ® The Journal

Volume 97

cost of amiodarone is higher than previously
recommended agents. Currently, the
average wholesale price of a 300 mg dose of
amiodarone is approximately $168.9

In conclusion, the AHA has revised
the Guidelines for Cardiopulmonary Re-
suscitation and Emergency Cardiovascular
Care. The Guidelines 2000 have signifi-
cant antiarrhythmic drug therapy changes
from the previous guidelines. One major
change in the new guidelines is the recom-
mended use of amiodarone in place of lido-
caine as first- line drug therapy of refractory
VF. Other significant changes are included
in the Guidelines 2000, and the reader is
encouraged to review the new guidelines
for completeness. ■

References

1 . American Heart Association.
Guidelines for Cardiopulmonary
Resuscitation Emergency Cardiac
Care. JAMA. 1992; 268:2212-2302.

2. Herlitz J, Ekstrom L, et al. Lidocaine
in out-of-hospital ventricular fibrilla-
tion. Does it improve survival?
Resuscitation. 1997; 33(3):199-205.

3. Borer JS, Harrison LA, et al. Benefi-
cial effect of lidocaine on ventricular
electrical stability and spontaneous
ventricular fibrillation during exper-
imental myocardial infarction. Am J
Cardiol. 1976; 37:860-863.

4- Gonzalez ER, Kannewurf BS, Ornato
JP. Intravenous amiodarone for ven-
tricular arrhythmias: overview and
clinical use. Resuscitation. 1998; 30:33-42.

5. Desai AD, Chun S, Sung RJ. The role
of intravenous amiodarone in the man-
agement of cardiac arrhythmias. Ann
Internal Med.1997 ;127 (4):294-303.

6. Kudenchuk PJ, Leonard A, et al. Ami
odarone for resuscitation after out-of-
hospital cardiac arrest due to vencular
fibrillation (ARREST). N Engl J Med.
1999;341:871-878.

7. American Heart Association in Colla-
boration with the International Liaison
Committee on Resuscitation. Guide-
lines 2000 for Cardiopulmonary Resus-
citation and Emergency Cardiovascular
Care. Circulation. 2000; 108(2): 1-157.

8. Cordarone® [package insert]. Philadel-
phia, Pennsylvania: Wyeth Labora-
tories, Inc; 1997.

9. Cardinale, V (ed.): Drug Topics Redbook ,
104th ed. Montvale, New Jersey, Med-
ical Economics Company, Inc., 2000.

Franks is a Pharm . D . candidate in the College
of Pharmacy at the University of Arkansas for
Medical Sciences in Little Rock. Watterson is with
the University Hospital of Arkansas. Dr. Smith
is with the division of cardiology, College of
Medicine, DAMS and John McClellan Veterans
Administration Hospital in Little Rock.

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Number 6

December 2000 • 199

wiillir

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HEALTH

WATCH

West Nile Fever
in the United States

In the summer and fall of 1999 the first cases ever of West
Nile Vims (WNV) infection occurred in the northeastern
United States. The original eight cases diagnosed were
clustered within a four-mile area of Queens New York. They
were all healthy adults between the ages of 58 and 85 years.
Symptoms included gastroenteritis, fever, altered mental status
and diffuse muscle weakness. Cerebrospinal fluid (CSF) and
peripheral blood parameters suggested a viral etiology.

Concurrent with the human outbreak there was an
increase in bird fatalities primarily
among crows. Birds are the primary
host for arboviruses such as St. Louis
Encephalitis and West Nile Fever.

Infected birds are usually asymp-
tomatic. The dead birds in this
outbreak, however, showed pathologic
evidence of viral encephalitis. Avian
tissue samples were sent to the
National Veterinary Service Labor-
atory, where a Flavivims was isolated
that was subsequently identified by the
CDC as West Nile Vims.

During the outbreak, which ran
from August-October, 62 humans
became clinically ill with seven deaths.

There were 25 equine cases with nine
deaths, and at least 14 species of birds
died of the infection. The dead birds
were predominately crows but also
included were blue jays, magpies,
flamingos, herons, ducks, pheasants,
eagles and others.

The question on everyone’s mind
was whether the disease would winter
over in birds or mosquitoes and recur
or spread to other states during the year 2000. That question
has been answered in the affirmative.

Nationally, as of Sept. 15, 2000, avian surveillance has
identified 1,471 West Nile infected birds from six states,
including Connecticut, New York, New Jersey, Massachusetts,
Rhode Island and New Hampshire. Ninety percent of the
birds are crows that readily die with the disease. So far this
year, New York has one equine case, Connecticut has three,
and New Jersey has one. During the year 2000, New York has
had 12 human cases and New Jersey one. These figures will
change rapidly during the late summer months of August and
September.

West Nile Fever is an arthropod borne human illness

characterized by an abrupt onset, fever, headaches, altered
mental status, photophobia, lymphadenopathy, myalgia, rash
and frequent muscle weakness. Meningoencephalitis is an
occasional complication. There is often a mild leucopenia with
a slight lymphocytosis. The CSF is clear with normal sugar
and elevated protein levels. There is a pleocytosis with
increased lymphocytes and polymorphonuclear leukocytes.
Most people infected show an antibody titer but are
asymptomatic. Many show a slight fever and headaches of a
few day duration and recover
completely. Meningoencephalitis
occurs in a small percentage of people
usually older than 50.

The etiological agent, West Nile
Virus, is named after the district of
Uganda in East Africa where it was first
isolated. It is one of the earliest human
arboviral infections to be documented
and was initially isolated in 1937 from
the blood of a febrile woman. Sub-
sequent studies showed WNV
antibodies in the human populations
of East and Central Africa. The
causative agent is a single strand RNA
virus about 45 nm in diameter of the
genus of Haviviruses. It is closely related
to other flaviviruses including St. Louis
Encephalitis, Japanese B Encephalitis,
Murray Valley Encephalitis and
Dengue Fever. Care must be taken in
the laboratory to distinguish between
the viruses, which cross-react on
certain diagnostic laboratory tests. The
New York outbreak was originally
thought to be St. Louis Encephalitis
because tests were positive for a flavivirus, and St. Louis
Encephalitis was the most logical diagnosis.

There are different strains of WNV in other countries of
the Eastern Hemisphere, and recently, it has been shown there
are antigenic variations between strains from the same region.
The strain of WNV isolated in New York was remarkable
because it killed birds, and in humans it often caused muscle
weakness that could be confused with Guillian Barre syndrome.

Occurrence

The vims has been isolated from vertebrates and arthropods
in 17 countries including India, Pakistan, Europe, Israel and
Russia. The outbreak in New York in August 1999, was the

Concurrent with the human outbreak there
was an increase in bird fatalities primarily
among crows . Birds are the primary host for
arboviruses such as St. Louis encephalitis
and West Nile Fever.

200 » The journal

Volume 97

WNV suspect patients normally present
with the following symptoms:

1. Fever greater than 100° F;

2. Altered mental status (confusion, lethargy,
agitation and other neurological symptoms)
to include palsies, paralysis, etc.;

3. An abnormal CSF profile including negative
bacterial stains, a pleocytosis with excess
lymphocytes and elevated protein;

4. Muscle weakness (especially flaccid)
confirmed by neurologic exam or EMC.

first occurrence of the virus in the
Western Hemisphere. It closely
resembles the strain of virus
found in Israel that was
previously isolated from geese.

Each year from mid-August
to November hundreds of
millions of birds cross Israel as
they migrate from Europe to the
warmer African climates. Some
of them carry West Nile Vims,
which is picked up by mosquitoes
and spread quickly to humans,
causing sickness ranging from a flu-like
illness to encephalitis. There are recent
reports that more than 120 cases of
WNV and eight deaths have occurred
in Israel this year. Hundreds of more cases
are suspected.

Hosts and Reservoirs

Serological studies have shown the
presence of WNV in almost all wild and
domestic animals, including cattle,
sheep, swine, goats, camels, rabbits, dogs,
rodents, primates, bats and others. Wild
and domestic birds are assumed to be the
primary host responsible for infecting
mosquitoes. Mosquitoes themselves are
capable of ovarial transmission of the
vims and therefore may carry the vims
over from year to year.

In South Africa 13 species of birds
experimentally infected with the vims
developed a viremia of three days
duration, sufficient to infect mosquitoes.
In Egypt, five species of birds exposed to
infected mosquitoes developed infectious
viremia for three to four days. Prevalence
rates between 10%— 50% have been
found in birds from Israel, Pakistan, Egypt
and South Africa.

Humans are readily infected by mo-
squitoes and develop a low-level viremia
that is probably insufficient to reinfect
mosquitoes. In humans, viremia is most
likely to occur on the first day of fever.
Viremia has been demonstrated in up to
77% of infected individuals during the
first day of fever. The rate dropped to 20%
on the second and third days of fever.

Prevalence and Susceptibility
of Human Populations

Human seroprevalence of more than
20% has been recorded in Israel,
Pakistan, Nigeria and India during

outbreaks of the disease. During the
1950s an estimated 40% of humans in
Egypt’s Nile Delta were serologically
positive. The seroprevalence rate
determined by random sampling in the
New York City area during the 1999
outbreak was 2.6%.

Transmission

Culex Pipiens and Resturans mo-
squitoes are mainly responsible for
transmitting the disease in the United
States. However, other species of
mosquitoes have been incriminated, in-
cluding Aedes Japonica. Bird migration
appears to be the major mechanism of
WNV dissemination. Widgeons
migrate from Eurasia to the Northeast
United States. Storms may dislocate
migratory birds. Exotic birds imported
to zoos may be responsible for bringing
in the virus. In addition, infected
mosquitoes may enter the United States
in aircraft.

Since the Culex mosquito loves to
feed on birds, they are the ideal vector.

Mites and ticks also are known to be
vectors, but their significance is thought
to be minor. Then there are factors in
epidemics that are not understood. Bats
and rodents experimentally inoculated
with WNV have shown viremia. The
strain of virus in the United States
results in bird die-offs that are explained
by the high concentration of virus in
the organs and central nervous system.
Certain species of birds are more
susceptible, especially crows. Chickens
and sparrows do not normally die of the
disease but are easily infected and
develop a viremia, sufficient to infect
mosquitoes.

Dr. Tracy McMamara, DVM at the
Bronx Zoo in New York, performed

necropsies on all dead birds and
reported gross hemorrhage of the
brains, splenomegaly, meningoen-
cephalitis and myocarditis as the
predominant gross pathological
findings. The organs were highly
viremic, enlarged, hemorrhagic or
inflamed. Twenty-seven birds
representing 14 species were ex-
amined. Virus was detected in 23/
26 brains; 24/25 hearts 15/18
spleens, 14/20 livers, 20/20 kidneys
10/13 outbreaks, 13/14 intestine,
etc. Viral concentration was high in the
tissues. This probably accounts for the
high mortality rate in certain birds. St.
Louis Encephalitis infection in birds does
not normally cause fatalities and gross
pathological changes to the extent seen
with WNV infection.

Surveillance for West Nile
Virus in Arkansas

The Center for Disease Control has
provided grant money to the Arkansas
Department of Health to develop a
program to detect WNV encephalitis in
Arkansans.

Physicians are requested to report
cases of aseptic meningitis and viral
encephalitis to the division of epide-
miology, Arkansas Department of
Health, (501) 661-2597 or (501) 661-
2 143, so arrangements can be made for
laboratory testing of serum and CSF for
WNV. Specimens to submit for
laboratory testing include acute sera
collected during the first week of
illness followed by convalescent phase
sera collected two-three weeks later.
Submit at least 2 ml. of each. Transport
with cold packs to reach the laboratory
within 24 hours if possible. CSF for
virus isolation requires at least 1 ml. in
a tube without preservatives. The
specimen must be frozen at -70° C
before shipping. ■

Please send samples to:

Arkansas Department of Health,
Immunology Laboratory
4815 W. Markham St., Slot #47
Little Rock, AR 72205

References: Handbook of Zoonoses
Second Edition, Section B Viral, CRC Press,
C.D.C. Bulletin on West Nile Virus.

Number 6

December 2000 • 201

SCIENTIFIC ARTICLE

Serial Troponin I Measurements Detect
Recurrent Myocardial Infarction
After Initial Acute Myocardial Infarction

Hani A. Razek, MD — Brian S. Erler, MD, Ph.D. — J. David Talley, MD

Abstract

Serial serum troponin I and CK-
MB measurements were obtained for
36 patients presenting to the emer-
gency department with a confirmed
diagnosis of acute myocardial in-
farction (AMI). For each patient, the
normalized percentage of maximum
troponin I concentration (%max
TropI) was plotted vs. the time from
the maximum value to obtain a kinetic
decay plot. The linear correlation plots
of the -Log (%max TropI) vs. time
were compared. Patients with uncom-
plicated AMI (n = 31) showed linear
correlation coefficients (CC) above
0.97 (meanCC = 0.991). Patients with
AMI complicated by recurrent myo-
cardial infarction (n = 5) documented
by corroborate clinical findings, elec-
trocardiographic abnormalities and/or
abnormal CK-MB results showed
linear correlation coefficients (CC)
less than 0.97 (mean CC = 0.763).
Using a cutoff value of CC = 0.97, both
patient groups were completely sep-
arated and re-infarction or extension

of infarction was predicted with 100%
accuracy, sensitivity and specificity.

Conclusion: Kinetic modeling of
troponin I decay in patients with AMI
correctly differentiates patients with
complicated vs. non-complicated
courses.

Introduction

Cardiac Troponin I (Tnl) is a pro-
tein subunit of the troponin complex
that is found only in the heart and is
released after myocardial necrosis.1,6
Serum peak values are proportional to
infarct size and are an independent
predictor of short-term mortality in
acute coronary syndromes even in the
absence of CK-MB elevation.5
Troponin I early kinetics are similar to
CK-MB.2,6 Since serial CK-MB
measurements show multiple peaks in
re-infarction or persistent elevation
with extension of infarction,7,8 we
attempted to determine whether
patients could be reliably separated into
groups showing “uncomplicated”
kinetics after acute myocardial in-

farction (AMI) and “complicated”
kinetics that would provide early
evidence of re-infarction or extension
of infarction.

Methodology

This was a retrospective, pilot
study of serial serum Tnl and CK-MB
measurements obtained from 36
patients presenting to the emergency
department with AMI. Aliquots of
serum were obtained through existing
indwelling peripheral catheters or at
the time of other planned veni-
puncture every four-eight hours on day
one and at intervals of eight and 24
hours on subsequent days. For quan-
titative determination of serum Tnl, a
fluorogenic enzyme-linked immun-
oassay (OPUS Troponin I assay) was
used; this assay uses two goat poly-
clonal antibodies that are purified to
recognize different polypeptide seg-
ments unique to the cardiac isoform
of troponin I (measuring range 0.5-
150 ng/ml). Values >1.5 ng/ml were
considered positive for Tnl in this

Figure 1: On plotting Tnl vs. Time, note the peak, then gradual decay, that occurred in all uncomplicated Ml, which
followed first order exponential decay with CC > 0.97 on plotting -Ln(%Max Tnl) vs. Time.

202 • The Journal

Volume 97

Figure 2: Plotting Tnl vs. Time, note the peak, with gradual decay, until re-infarction occurred with a rise Tnl, with no
linear correlation and CC near 0 on plotting -Ln(%Max Tnl) vs Time.

study. The intra-assay coefficients of
variation were from 4-6% — 1 2% at
values from 2.99 ng/ml-104 ng/ml.
Validity of this assay has been proven
in a multi-center clinical study.3 For
each patient, the normalized per-
centage of maximum troponin I
concentration (%maxTropI) was
plotted vs. the time from the max-
imum value to obtain a kinetic decay
plot. Kinetic decay curves were
analyzed without knowledge of the
patient’s clinical course and charts
were reviewed to determine the
presence or absence of complications
of AMI without knowledge of serial
Tnl determinations.

Results

Patients with AMI complicated by
recurrent myocardial infarction or
extension of infarction (n = 5) showed
troponin I decay plots with secondary
peaks. These patients with com-
plicated AMI had corroborating
clinical findings, EKG abnormalities
and/or abnormal CK-MB results.
Patients with uncomplicated AMI (n
= 31) showed first order exponential
decay kinetics of troponin I concen-
tration with a decay constant K =

0.812 +/- 0.219 (mean +/- SD). Linear
correlation plots of the - Log
(%maxTropI) vs. time were compared
for both patient groups. The unc-
omplicated AMI group showed linear
correlation coefficients (CC) above
0.97 (mean CC = 0.991) confirming
the validity of the exponential decay
kinetics model (Figure 1). Significant
deviation from this kinetic model was
seen for the complicated AMI group

(Figure 2) with linear correlation
coefficients (CC) less than 0.97 (mean
CC = 0.763). Using a cutoff value of
CC = 0.97, both patient groups were
completely separated and recurrent
myocardial infarction or extension of
infarction was predicted with 100 %
accuracy, sensitivity and specificity.

Discussion

After an AMI, approximately 20%
of patients subsequently develop re-
infarction or extension of their in-
farction during their hospitalization.7,8
The significance of silent ischemia in
this group has been well-documented.9
This also has been documented after
thrombolytic therapy and angioplasty.
Of the available biochemical markers,
CK-MB has been widely used to
detect recurrent myocardial infarction
or extension because it is labile and
has an earlier clearance after an AMI.1
Tnl, which is an inhibitory subunit
of the troponin complex, has early
kinetics similar to those of CK-MB.
It can be detected in the serum
slightly before CK-MB (4 h after
infarction), peaks after CK-MB
(about 14-18 h) and persists for
seven-10 days after myocardial
injury.2,6 There is a 13 fold greater
concentration of Tnl than CK-MB in
the myocardium on a weight basis,
thus the signal to noise ratio
associated with Tnl is much more
favorable for detecting minor cardiac
necrosis.1,5 It has been documented
that Tnl is not detected in the serum
of healthy individuals,2,5 acute or
chronic muscle disease, following
vascular or non-cardiac surgery or

after muscle injury1,2,6 and is not
affected by renal failure, 1 whereas
CK-MB is found in the serum of
healthy individuals and is affected by
muscle injury and renal failure. Wu et
al has reported a Tnl sensitivity of
100% by 6 h after AMI with an average
specificity of 96%, thus making it a
more cardiospecific and sensitive
marker.10 In our study, we tested the
hypothesis that, although Tnl persists
for five-seven days, by continually
monitoring the daily decline of serum
Tnl for approximately five days, any
deviation from the expected decline
(plateau or rise of serum Tnl) would
predict recurrent myocardial in-
farction or extension. This pilot study
suggests that this hypothesis is correct
and that serial Tnl measurements may
be useful in identifying a subset of
patients with AMI who are beginning
to extend their infarction or re-
infarct. Further prospective analysis
will help to define the validity of this
hypothesis and the true clinical utility
of serial Tnl determination in this
setting. ■

References

1. Keffer JH. Cardiac profile and
proposed practical guideline for
acute ischemic heart disease. Am
J Clin Pathol 1997; 107(4):398-
409.

2. Bertinchant JP, Larue C, Pemel
I, Ledermann B, Fabbro-Peray P,
Beck L, Calzolari C, Trinquier S,
Nigond J, Pau B. Release kinetics
of serum cardiac troponin I inis-
chemic myocardial injury.
Clinical Biochemistry 1996;

Number 6

December 2000 • 203

29(6):587'594.

3. Larue C, Calzolari C, Bertinchant
JP, Leclercq F, Grolleau R, Pau

B. Cardiac-specific immunoen-
zymometric assay of troponin I in
the early phase of acute myocar-
dial infarction. Clinical Chemistry
1993;39(6):972-979.

4. Adams JE 3d, Bodor GS, Davila-
Roman VG, Delmez JA, Apple
FS, Ladenson JH, Jaffe AS.
Cardiac troponin I. A marker
with high specificity for cardiac
injury. Circulation 1993;

88( 1 ): 101 - 106.

5. Antman EM, Tanasijevic MJ,
Thompson B, Schactman M,
McCabe CH, Cannon CP,

Fischer GA, Fung AY, Thompson

C, Wybenga D, Braunwald E.
Cardiac-specific troponin levels to
predict the risk of mortality in
patients with acute coronary syn-
dromes. N Engl J Med 996; 335

( 18): 1342- 1 349.

6. Wong SS. Strategic utilization of

cardiac markers for the diagnosis
of acute myocardial infarction.
Annals of Clinical and
Laboratory Science 1996;26
(4):301-312.

7. Buda AJ, Macdonald IL, Dubbin
JD, Orr SA, Strauss HD.
Myocardial infarct extension:
prevalence, clinical significance,
and problems in diagnosis. Am
Heart J 1 983; 1 05 ( 5 ): 744-749.

8. Weisman HF, Healy B.
Myocardial infarct expansion,
infarct extension, and
reinfarction: pathophysiologic

concepts. Prog Cardiovasc Dis
1987;30(2):73-110.

9. Gill JB, Cairns JA, Roberts RS,
Costantini L, Sealey BJ, Fallen
EF, Tomlinson CW, Gent M.
Prognostic importance of
myocardial ischemia detected by
ambulatory monitoring early
after acute myocardial
infarction. N Engl J Med
1996;334(2):65-70.

10. Wu AH, Feng YJ, Contois JH,
Pervaiz S. Comparison of
myoglobin, creatine kinase-MB
and cardiac troponin I for
diagnosis of acute myocardial
infarction. Ann Clin Lab Sci
1996; 26(4):291-300.

1 1 . Apple FS, Henry TD, Berger CR,
Landt YA. Early monitoring of
serum cardiac troponin I for
assessment of coronary
reperfusion following
thrombolytic therapy. Am J Clin
Pathol 1996;105(1):6-10.

Dr. Razek is with the department
of internal medicine and division of car'
diology at the University of Arkansas
for Medical Sciences Medical Center
and the John L. McClellan Memorial
Veterans Hospital, Little Rock. Dr. Erler
is with the department of pathology at
Jersey Shore Medical Center, Neptune,
N .J . Dr. Talley is a cardiologist in
Paducah, KY.

To protect your reputation, we
take every claim seriously.

^StRiul

©2000 St. Paul Fire and Marine Insurance Company
Coverages underwritten by St. Paul Fire and Marine Insurance
Company or another member of The St. Paul Companies
www.stpaul.com

204 • The Journal

Volume 97

PEOPLE+EVENTS

Joseph Martindale (second from left) , director of the Arkansas Medical Foundation, receives a
$20,000 check from (left to right) Thad DeHart, SVMFs marketing representative , Steven
Williams, chief executive officer ofSVMI, and Randy Meador, SVMFs vice president of marketing

Special Thanks to State Volunteer Mutual Insurance Co.

We would like to present a special thank you to State Volunteer Mutual Insurance Co. (SVMI)
for its continued support of the Arkansas Medical Foundation (Physicians Health Committee).
Recently, SVMI presented the foundation with a check for $20,000. SVMI feels this contribution
is an investment. Tennessee’s program has been successful in reducing malpractice claims.

State Volunteer Mutual Insurance Co., organized by the Tennessee Medical Association, has
been very supportive of other activities of the Arkansas Medical Society.

HONORED

Dr. Logan Named
Association President

Dr. Charles W. Logan has

been elected president of the
South Central Section of the
American Urological Asso-
ciation.

The South Central Section
is a regional
urological
association,
including
Arkansas,
Missouri,
Kansas, Ne-
braska, Ok-
l a h o m a ,
New Mexico, Colorado, Texas,
Central America and Mexico.
The South Central Section
holds an annual meeting with
five days of scientific programs,
showcasing various academic
programs.

Springdale Physician
Named Cancer Liaison

Dr. Andre B. Whiteley of

Springdale recently received a
three-year appointment as
cancer liaison physician for the
Hospital Cancer Program at
Washington Regional Medical
Center in Springdale.

Dr. Whiteley is among a
national network of more
than 1,800 volunteer cancer
liaison physicians who provide
leadership and support to
Commission on Cancer pro-
grams, sponsored by the Amer-
ican College of Surgeons.

Monticello Physician
Honored by Residents

Dr. Ralph Maxwell of

Monticello received the Out-
standing Extramural Faculty
Teaching Award from residents

at the University of Arkansas for
Medical Sciences.

Each year, a number of
residents come to Monticello’s
Drew Memorial to observe
local doctors.

Camden Physician,
Doctor of the Year

Dr. Lawrence F. Braden,

a family physician at Ouachita
Valley Family Practice Clinic in
Camden, has been named the
2000-2001 Arkansas Family
Doctor of the Year by the
Arkansas Academy of Family
Physicians.

Dr. Braden, who was bom
in Hawaii, is a U.S. Navy
Vietnam veteran. He com-
pleted his medical degree at
U AMS and is a diplomat of the
American Board of Family
Practice. For many years he has
served as a preceptor for family
practice residents, interested

high school students and
medical students. This past
year, he spent one day a week
promoting rural health practice
to medical students.

Dr. Braden is active in the
community, helping found the
Christian Health Center, a
community clinic providing
care to the working poor. He
was recently named as health
officer for Ouachita County.

Dr. Braden, who has been
married for 31 years to wife
Dyan, has three children.

UAMS Physician
Named Surgery
Association President

Dr. Nicholas P. Lang,

professor of surgery and asso-
ciate director of the residency
program at UAMS in Little
Rock, has been named pres-
ident of the Southwestern Sur-
gical Congress.

Dr. Lang, chief of surgical
service at the Central Arkansas
Veterans Healthcare System, is
a native Arkansan, who grad-
uated from UAMS in 1973.
The Southwestern Surgical
Congress has members in 16
states and promotes the progress
of surgery.

AMA Names
PRA Recipients

Each month the American
Medical Association presents
the Physician’s Recognition
Award to those who have
completed acceptable pro-
grams of continuing education.

AMA recipients for April
include Drs. Roy D. Coleman
of White Hall; Kenneth P.
Collins of Harrison; Jonathan
M. Cook and Lynda B.
Milligan of North Little Rock;
Rebecca R. Hoyd of Van Buren;
Edward J. Jones of Batesville;

Dr. Logan

Number 6

December 2000 • 205

Robert L. Kerr and Kenneth
M. Kilgore of Mountain
Home; Glen C. Knowles of
Bradford; Albert S. Koenig of
Fort Smith; James Z. Mason
and David R. Rozas of Little
Rock; Elvin L. Norris of
Beebe; and Robert L. Prosser
of McGehee.

Jonesboro Physician
Honored by Clinic

Dr. Doug Maglothin, a

Jonesboro family practice
physician, was recently recog-
nized by the board of directors
of the Jonesboro Church
Health Center for his eight-
year tenure as medical director
of die facility.

Dr. Maglothin will he
succeeded by Dr. William Hurst.

During Dr. Maglothin’s
tenure, about 9,000 patients
were served at the clinic, which
provides health care and
counseling services to persons
with no insurance.

Pine Bluff Resident
Presented Award

Dr. Kristy Clinton Cow-
herd, a third-year family med-
icine resident at AHEC-Pine
Bluff, has been selected as one
of 20 recipients of the Mead
Johnson Awards for Graduate
Education in Family Practice.

Mead Johnson paid for
Dr. Cowherd to attend a Sep-
tember award banquet in
Dallas. She is a 1998 UAMS
College of Medicine graduate.

OBITUARIES

Dr. Karen L. Colwell

Dr. Karen Louise Col-
well, 44, an internist in Little
Rock died Sept. 12.

Dr. Colwell was bom in
Benton and attended the

University of Arkansas at Fay-
etteville and UAMS. Friends
and family say Dr. Colwell was
devoted to her sons and was
active in their activities, such
as scouting.

She is survived by her sons,
James Henry and Mark Henry
of Little Rock; her parents, Lee
and Barbara Colwell of Little
Rock; brother Paul Lee Col-
well of Dallas; and numerous
other relatives.

Dr. Rex C. Ramsay Jr.

Dr. Rex C. Ramsay Jr.,

72, of Hot Springs died Aug.
28.

Dr. Ramsay, bom in Nash-
ville, Ark., was the former
director of the state Depart-
ment of Health from 1974-
1979. He also was past medical

director for the Alcoa plant in
Bauxite and a retired captain
of the U.S. Naval Reserves.

Dr. Ramsay was awarded
the 1999 Distinguished Ser-
vice Award Lifetime Achieve-
ment Award by the American
Lung Association.

He is survived by his wife
of 46 years, Tee Ramsay of
Hot Springs; two sons and a
daughter-in-law, Pat and
Brenda Ramsay and Larry
Ramsay, all of Dallas; four
daughters and son-in-laws,
Cheryl and Tollie Green of
Hot Springs, Wendy and Jim
Liszewski of Dallas, Becca and
Lee Winningham of Center
Ridge and Christy and Mace
Robinson of Pearcy; two
sisters; 1 1 grandchildren; and
two great-grandchildren. ■

Correction In the October 2000 issue, Dr. Lonnie Harrison was incorrectly identified. Dr.
Harrison is proctoring the Arkansas Heart Hospital in Little Rock and is proctoring the chief
of cardiology at the Oshner Clinic in New Orleans, University of Alabama and several other
cardiac programs in the country.

ARE YOU LOOKING TO SLOWDOWN?

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Staff Physicians and Medical Directors Needed.

Primary & Supplemental Opportunities available in Heber Springs, Jonesboro, Searcy
Walnut Ridge, Wynne. Annual Volumes Range 6,500 to 35,000.

Must be BC/BP EM or PC, Residents welcomed in some locations, ACLS/ATLS/PALS.
Phy America offers competitive remuneration, IC status and procured malpractice.

For more information on this and other opportunities in Arkansas, please contact
Traci Mahlmeister, Physician Recruiter at Phy America Physician Services,
800-476-5986, fax CV to 919-382-3274, or e-mail tmahlei@phyamerica.com.

206 • The Journal

Volume 97

Membership

Roster

Arkansas Medical Society
Celebrating 125 Years

American Medical Association
Principles of Medical Ethics

I. A physician shall be dedicated to
providing competent medical service
with compassion and respect for
human dignity.

II. A physician shall deal honestly with
patients and colleagues, and strive to
expose those physicians deficient in
character or competence, or who
engage in fraud or deception.

III. A physician shall respect the law and
also recognize a responsibility to seek
changes in those requirements which
are contrary to the best interests of the
patient.

IV. A physician shall respect the rights of
patients, of colleagues, and of other
health professionals, and shall
safeguard patient confidences within
the constraints of the law.

V. A physician shall continue to study,
apply and advance scientific
knowledge, make relevant infonnation
available to patients, colleagues, and
the public, obtain consultation, and use
the talents of other health
professionals when indicated.

VI. A physician shall, in the provision of
appropriate patient care, except in
emergencies, be free to choose whom to
serve, with whom to associate, and the
environment in which to provide
medical services.

VII. A physician shall recognize a

responsibility to participate in activities
contributing to an improved
community.

Number 6

December 2000

207

Arkansas • Boone County

Arkansas Medical Society 2000 Membership Roster

Arkansas Medical Society

2000 Membership Roster

As of Oct. 2, 2000 — Please note: If you can’t find a particular physician in the county listings, look under the Direct
Member Section beginning on page 220. Direct Member indicates AMS members who are not members of their county
medical society or whose county membership was pending at the time of this Journal’s printing. # Denotes deceased member.

Arkansas County

Barwick, Loring Jr.
Burleson, Stan W.
Daniel, Noble B. Ill
Elam, Garrett
Ferrari, Victor J. Jr.
Hestir, John M.

Hord, Marion E.
Millar, Paul H. Jr.
Northcutt, Carl E.
Pritchard, Jack L.
Speer, Hoy B. Jr.
Speer, Marolyn N.
Wood, Gary P.
Yelvington, Dennis B.

Ashley County

Burt, Frederick N.
Garcia, Luis F.
Gresham, Edward A.
Heder, Guy W.

Henry, William Jr.
Kula, Zhigtniew
Malloy, Mark
Rankin, James D.
Salb, Robert L.
Thompson, Barry V.
Toon, D. L. #
Wagoner, Charles H.
Walsh, Benjamin ).
Wilson, Alan K.

Baxter County

Adkins, Kevin J.
Baker, Robert L.
Barker, Monty
Barnes, Gregory
Bruton, Ronald Ford
Burgess, Richard C.
Chatman, Ira D.
Cheney, Maxwell G.
Chock, Daniel P.
Clarke, James S.
Cogburn, Bob E.
Condrey, Yoland M.
DeYoung, Bruce
Dyer, William
Dykstra, Peter C.
Elders, John Gregory

Foster, Robert D.
Gocio, John C.
Hagaman, Michael S.
Hardin, Philip R.
Hodges, Michael E.
Johnson, Stacey M.
Kelley, Lawrence A.
Kerr, Robert L.
Kilgore, Kenneth M.
Knox, Thomas E.
Landrum, William
Lawrence, George S.
MacKercher, Peter A.
Massey, James Y.

May, Brett H.
McAlister, Matthew
McBride, Anthony D.
McKelvey, Kent D. Jr.
Millstein, David I.
Neis, Paul R.

Price, Michael D.
Regnier, George G.
Robbins, Bruce
Roberts, David H.
Saltzman, Ben N.
Sneed, John W. Jr.
Stahl, Ray E. Jr.

Sward, David T.
TerKeurst, John
Tullis, Joe M.

Turner, Frederick C.
Wells, Gary
White, Edward
White, Richard B.
Wilson, Jack C.

Wren, Mary

Benton County

Addington, Alfred R.
Alderson, Roger
Allen, L. Barry
Arkins, James
Baker, James
Ball, Eugene H.
Becton, Paul Jr.
Benjamin, George
Berry, Michael F.
Black, Randall Wayne
Bledsoe, James H.

Boden, Donna
Boozman, Fay W. Ill
Cantwell, Janet
Clemens, R. Dale
Cole, Randall E.

Cooper, Scott
Costaldi, Mario E.
Cuchia, John
Dang, Minh'Tam
David, Wendy S.
Deatherage, Joseph R.
Diacon, W. Lindley
Dickinson, Rodger C. Jr.
Donnell, Robert W.
Elkins, James P.

Emerson, Kimberly
Ewart, David
Fangmeier, Angela Anne
Fioravanti, Bernard L.
Friesen, Douglas L.
Garrett, David C. Ill
Goss, Stephen
Haney, R. Kevin
Hill, Joy
Hitt, Jerry L.

Hof, C. William
Holder, Robert E.

Horner, Glennon A.
Hull, Robert R.

Huskins, James D.
Johnson, Donna
Johnson, Royce Oliver II
Johnson, Steven P.

Jones, Nancy
Keane, Patrick K.

Lanier, Karen A.

Lewis, Rebecca C.

Low, Lisa

Lueders, Andrew J.
Marciniak, Douglas L.
McAlister, Robin
McCollum, William
McKnight, William D.
Meehan, Ralph E. Jr.
Mertz, John Douglas
Mullins, Neil D.

Nugent, Loyd
Pappas, John J.

Pearson, Richard N.

Pickens, James L.

Platt, Michael R.
Poemoceah, Kenneth M.
Puckett, Billy J.

Reese, Michael C.
Revard, Ronald
Ritz, Ralph C.

Rollow, John A.

Rolniak, Wallace A.
Schaefer, George
Springer, Dan J .
Steadman, Hunter M. Jr.
Stinnett, Charles H.
Stinnett, Scott G.

Stolzy, Sandra
Swaim, Terry J.

Swindell, William G.
Tate, Jeffrey
Thompson, Alice A.
Travis, Patrick
Treptow, Douglas
Turley, Jan T.

Ubben, Kenneth
Vanderpool, R. Douglas
Vest, Carl E.

Warren, Grier D.
Weaver, Robert H.
Webb, William
Whiteside, Edwin
Wilson, Cynthia
Wright, Larry D.
Youngblood, Thomas

Boone County

Abdelaal, Ali F.

Ashe, Barbara
Bell, Thomas Edward
Bennett, Joe D.

Brandon, Henry
Causey, Robert Marcus
Chambers, Carlton L. Ill
Chambers, Sue
Clary, Cathy
Collins, Kenneth
Daniel, Charles D.
Dunaway, Geoffrey
Ferguson, Noel F.
Flanigan, Stevenson
Ghosh, Asish Kumar

208 • The Journal

Volume 97

2000 Arkansas Medical Society Membership Roster

Boone - Craighead-Poinsett County

Hawk, James M.
Helmling, Robert L.

Kim, Hyewon
Klepper, Charles R.
Langston, James David
Langston, Robert H.
Langston, Thomas A.
Ledbetter, Charles A.
Leslie, Sharron J.

Maes, Stephen R.
Mahoney, Paul L. Jr.
Maris, Mahlon O.
McNutt, Joseph
Mears, Bill
Miller, Robert Jr.

Padilla, Jose S. Jr.

Reese, Ronald R.
Scroggins, Sam J.
Steinsiek, J. Bill II
Van Ore, Stevan Michael
Vowell, Don R.

Waters, James Dana
Williams, Rhys A.

Bradley County

Chambers, F. David
Engelkes, LaDonna D.
Foscue, David
Marsh, James W.
Pennington, Kerry F.
Purvis, Kenneth W.
Wharton, Joe H.

Wynne, George F.

Carroll County

Albrecht, Tammy G.
Card, Shannon R.

Corrie, Doug
Flake, William K.

Horton, Charles
Kresse, Gregory
Malone, Mark S.
Martinson, Alice
Nash, John R.

Ricciardi, Joseph M.

Rose, Steve
Sloan, Fredric J. II #
Spurgin, Randal T.
Stensby, Harold F.

Taylor, Richard L.
Wallace, Oliver
Warner, Milo N.

Chicot County

Burge, John P.

De Ramos, Agapito Y.
Folk, Benjamin Perry
Ganta, Sanyasi Rao
Hicks, Charles E.

Kronfol, Ned
Martin, Andrew Ayers
Russell, John R.

Smith, Major E.
Thomas, H. W.
Tuangsithtanon, T.
Weaver, William J.
Wilson, Thomas C.

Clark County

Anderson, P. R.

Balay, John W.
Dorman, Robert A.
Elkins, John S.

Ford, Michael Ray
Fullerton, John C. Ill
Hagood, Noland Jr.
Jansen, Mark
Lowry, James L.
McLeod, Kevin
Peeples, George R.
Taylor, George D.

Teed, Frank S.

Cleburne County

Ashabranner, Wesley J.
Baldridge, Max
Barnett, Michael
Bivins, Franklin Jr.
Lambert, James C.
McNair, James R.
Quinn, Cynthia D.
Sharp, Jan
Stone, Timothy
Thomas, Jerry L.
Tvedten, Tom
Vaughan, G. Lee

Columbia County

Alexander, John E. Sr.
Alexander, John E. Jr.
Dickson, D. Bud
Edwards, Frank Damon
Evans, Matthew L.
Farmer, John M.
Griffin, Rodney L.
Hester, Joe D.

Kelley, Charles W.
McMahen, H. Scott
Murphy, Fred Y.
Parkman, Robert L. Jr.
Pullig, Thomas A.
Roberts, Franklin D.
Walker, Jack T.

Wynn, Chester

Conway County

Hickey, Thomas H. #
Lipsmeyer, Keith M.
Owens, Gastor B. #
Wells, Charles F.

Craighead-Poinsett

County

Allen, John M.

Alston, Herman D.
Ameika, James A.
Aston, J. Kenneth
Awar, Ziad
Ball, John
Barker, Charles
Basinger, James W.
Beck, M. Lowery
Behrens, Bing X.

Berry, Donald M.

Berry, Michael P.
Blachly, Ronald J.
Blaylock, Jerry D.
Braden, Terence P. Ill
Brown, Mark C.

Burns, Richard G.
Burns, Robert
Carpenter, Kennan
Clopton, Owen H. Jr.
Cohen, Robert S.
Cook, John
Cranfill, Ben
Cranfill, General L. Ill
Crawley, Michael E.
Day, Thomas Elkins
Degges, Russell D.
Delacey, Norbert Jr.
Diamond, Kevin
Dickson, Glenn E.

Dow, J. Timothy
Dudley, Millicent
Duke, Billy L. II
Dunn, Charles C.
Eddington, William R.
Edwards, Carl B.
Emerson, Steven
Eubanks, K. Dewayne
Felts, Larry S.

Fields, L. Brad
Foote, John W.
Forestiere, A. J.
Ganong, Kevin Donald
Garner, B. Matt
Garner, William L.
George, F. Joseph
Golden, Stephen C.
Good, Daniel J.
Gossett, Clarence E.
Green, Terri
Green, William Robert
Guinn, Donald R.
Hackbarth, Mark A.
Hall, Ray H. Jr.

Harvey, Bryan
Hatley, Russell
Hiers, Connie L.
Hightower, Michael D.
Hill, Roger D.

Hogue, Ernest L.

Hong, Michael Tzuoh
Hornbeck, Robert G.
Houchin, Vonda

Hurst, William
Isaacson, Michael L.
Jennings, R. Duke
Jiu, John B.

Johnson, John A.

Johnson, Larry H.

Johnson, Roehl W.

Jones, K. Bruce
Jones, R. J.

Kalife, Gerardo
Keisker, Henry W.

Kemp, Charles E.

Kroe, Donald J.

Laffoon, Scott L.

Lamb, Trent R.

Landry, Robert J .

Lansford, Bryan
Lawrence, Robert O. Jr.
Ledbetter, Joseph W.
Lepore, Diane G.

Levinson, Mark
Lewis, David M.

Locke, Stephen Wayne
Lunde, Stephen P.

Luter, Dennis W.

Lynch, John
Mackey, Michael
Maglothin, Douglas L.
Mahon, Larry E.
Marzewski, David
Matthews, David
McClurkan, Michael
McDaniel, Craig A.
McGrath, A. Joseph Jr.
McKee, Sanders
Monte, Marc
Montgomery, Earl W.
Moseley, Claiborne II
Owens, Ben Jr.

Parten, Dennis
Patel, Suresh
Phillips, John K.

Price, Edwin F.

Price, Herbert H. Ill
Ragland, Darrell G.
Rainwater, W. T.

Rauls, Stephen R.
Reinhard, Richard Mast III
Ricca, Dallie
Ricca, Gregory F.

Richards, Fraser M.

Rogers, James F.

Rusher, Albert H. Jr.

Sales, Joseph Hugh
Sanders, James W.

Sapiro, Gary S.

Savage, Patrick Joseph
Schrantz, James L.

Scriber, Ladd J .

Scroggin, Carroll D. Jr.
Shanlever, William T.
Sifford, Mark

Number 6

December 2000 • 209

Craighead-Poinsett - Garland County

Arkansas Medical Society 2000 Membership Roster

Skaug, Phyllis
Skaug, Warren A.
Smith, Floyd A. Jr.
Smith, Vestal B.

Sneed, Jane
Snodgrass, Scot J.
Sparks, Barrett
St Clair, John T. Jr.
Stainton, Robert M. Jr.
Stallings, Joe H. Jr.
Stank, Thomas M.
Stevenson, Richard
Stidman, Jeff
Stripling, Mark C.
Stroope, Henry F.
Stubblefield, Sandra
Stubblefield, William
Swingle, Charles G.
Tagupa, Eumar
Taylor, Robert D.
Tedder, Barry C.
Tedder, Michael E.
Templeton, Gary L.
Tidwell, Kenneth Jr.
Tonymon, Kenneth
Tuck, Rebecca
VanScoy, Sara Elsie
VanScoy, William R.
Vines, Troy Alan
Vollman, Don B. Jr.
Walker, Meredith M.
White, Anthony T.
Wiggins, H. Lynn
Wilson, Joe T. Jr.
Woloszyn, John
Woodward, Gary W.
Young, William C. Jr.

Crawford County

Archer, Ernest W.
Darden, Lester R.
Darrow, Bruce A.

Delk, John II
Dillard, Carolyn
Edds, Millard C. #
Edwards, Henry N.
Floyd, Rebecca R.
Garrett, Kipton L.
Hamby, Jeffrey
Harford, Scott
Heaver, Holly M.
Hefner, David P.
Jennings, Charles A.
Katz, Catherine
Mason, Joe N.

Ross, R. Wendell
Sasser, L. Gordon III
Schlabach, Ronald D.
Stanton, William B.
Travis, A. Lawrence
Whatcott, Brett

Crittenden County

Adler, Justin Jr.

Arnold, Sidney W.

Barr, Marian
Bryant, G. Edward Jr.
Clemons, Mark
DeRossitt, James P. Ill
Deneke, Milton D.
Evans, Loraine J.
Ferguson, Scott
Ferguson, T. Murray #
Ford, David W.

Ford, Robert C. Jr.
Goodman, David Aaron
Hernandez, Jacinto
Huffstutter, Paul J .
Kaplan, Bertram
L’Heureux, Guy J.

Lum, Diane
Miller, James L.

Mirza, Mashhud Munir
Murray, Ian F.

Nadeau, Kenneth R.
Peeples, Chester W. Jr.
Peeples, Guy Langley
Pierce, Trent P.

Rudorfer, Bennett Lewis
Ruiz, Julio P.

Salgueiro, Carlos A.
Schoettle, Steve P.
Shrader, Floyd R.

Smith, Bedford W.
Utley, L. Thomas
Valdes, Raymond P.
Wah, John
Ward-Jones, Susan
Wehb, Dan W.
Westmoreland, Daniel
Wright, William J.

Cross County

Beaton, J. Trent
Beaton, Kenneth E.
Burks, Willard G.

Crain, Vance J.

Hayes, Robert A. Jr.
Jacobs, James R.

Rindt, Phillip Lee

Dallas County

Delamore, John H.
Howard, Don G.

Nutt, Hugh A.

Wilkin, Timothee

Desha County

Asemota, Steve
Go, Peter Kong Hua
Harris, Howard R.
Masquil, Filipe
Mehta, Hemal
Prosser, Robert L. Ill

Scott, Robert B.

Stewart, R. Todd
Turney, Lonnie R.

Young, James E.

Drew County

Busby, Arlee K.

Connelley, Jay
Huey, Sandra S.

Maxwell, Ralph M.
Reinhart, Jeffrey
Ridout, Robert G. III.
Wallick, Paul A.

Williams, William III
Wilson, Harold F.

Faulkner County

Angel, Carol
Beasley, Margaret D.
Beasley, Thomas O.

Bell, F. Keith
Bowlin, Randal
Bowman, Gary
Carter, D. Mike
Cheek, Ben H. #

Cole, Andrew
Collins, Mitchell L.
Connaughton, Michael A.
Cummins, J. Craig
Daniel, Sam V.

Dobbs, John C.

Dodge, Ben
France, Diane P.

Furlow, William C.
Garrison, James S. #
Ghormley, J. Tod
Gordy, L. Fred Jr.

Gullic, Phillip T.
Hendrickson, Richard O. Jr.
Hudson, Thomas F. Ill
Jackson, Carole
Kendrick, Gregory
Landberg, Karl H.

Landgren, Robert C.

Lewis, Gregory
Magie, Jimmie J.

Martin, David A.
McChristian, Paul L.
Murphy, Kenneth
Naylor, David L. Jr.

Norris, Lloyd P.

Ohrn, Maria A.K.

Raney, Herschel D. Jr.
Roberts, Thomas
Shaw, Collie B.

Shirley, David C.

Smith, John D.

Smith, Lander A.

St. Amour, Scott C.

Stancil, Vicki
Stone, Phillip
Throneberry, Bart

Trussell, Anne
Tsuda, Sue

Franklin County

Carrick, Garreth
Gibbons, David L.
Lachowsky, John
Long, C. C.

Smith, John C.
Westbrook, Michael R.
Wilson, Robert

Garland County

Abraham, Jacob E.
Agee, Kimberly R.
Arthur, James M.
Aspell, Robert
Bandy, Preston R.
Barnes, Jerome D.
Bearden, Jeffrey C.
Bennett, Keith
Bodemann, Diane
Bodemann, Donald R.
Bodemann, Michael C.
Bodemann, Stephen L.
Bohnen, Loren O.
Boos, Donald Jr.

Borg, Robert V.
Borland, Judy
Braley, Richard E.
Brandt, John O.

Braun, James R.
Brunner, John H.
Bumpas, Timothy F.
Burton, Frank M. #
Burton, James F.
Campbell, James W.
Capel, Denise Louise
Cates, Jack A.

Cenac, Joseph W. Jr.
Clardy, William F.
Cupp, Cecil W. Ill
Davis, Katrina
Davis, Sheryl L.

Dodd, Lawrence
Dodson, John W. Jr.
Dolan, Patrick III
Drake, Gary M.

Dunn, Richard W.
Dykman, Kathryn
Eisele, W. Martin
English, P. Timothy
Erwin, John
Finch, Richard R.

Fine, B.D. Jr.

Fore, Robert W.

Fotioo, George J.

Frais, Michael A.
French, James H.
Gammill, Todd
Gardner, James L.
Garrett, W. Michael

210 • The Journal

Volume 97

2000 Arkansas Medical Society Membership Roster

Garland - Independence County

Gerber, Allen D.
Griffin, James E.
Grose, Andrew
Haggard, John L.

Hale, Kevin D.

Hardy, Ross A.

Harper, Edwin L.
Harrison, Jack W.
Headrick, Daniel
Hechanova, D. M. Jr.
Heinemann, Fred M.
Heinemann, Phyllis E.
Henderson, Francis M.
Herrold, Jeffrey W.
Hickman, Michael P.
Hill, H. Randy
Hill, Robert L.

Hitt, W. C. Jr.

Hollis, Thomas H.
Horner, Charles R. Jr.
Howe, H. Joe
Hughes, James A.
Hulsey, Matthew
Humphreys, Robert P.
Hunter, Karla
Irwin, William G.
Jackson, Brian D.
Jackson, Haynes G.
Jackson, Haynes G. Jr.
Jayaraman, Vilasini D.
Johnson, Paulette S.
Johnson, Robert D.
Johnston, Gaither C.
Josef, Stanley
Kaler, Ron A.

Keadle, William R.
Kincheloe, A. Dale
Kleinhenz, Robert W.
Klugh, Walter G. Jr.
Koehn, Martin A.
Larey, Mark E.

LeMay, Thomas B.

Lee, Allen R.

Lee, William R.

Longo, Margaret F.
Lucas, Shauna L.
Martin, Jana
Maruthur, Gopakumar
Mashburn, William R.
Mathews, John S.
McClard, Helen
McCrary, Robert F. Jr.
McFarland, Mike S.
McMahan, James
Meek, Gary N.

Munos, Louis R.

Olive, Robert Jr.

Pace, John Robert
Pai, Balakrishna
Pappas, Deno P.
Parkerson, Cecil W.
Peeples, Raymond E.

Pellegrino, Richard
Pilkington, Cheryl E.
Plaza, Jesus’ A.

Powell, Brenda
Queen, George P.
Rainwater, W. Sloan
Raney, Jerel L.

Reddy, Prabhakara K.
Robbins, Mark
Robert, Jon M.

Rogers, Marc
Roper, Richard
Rosenzweig, Joseph L.
Russell, Mark
Sanders, Hallman E.
Seifert, Kenneth A.
Sharma, Bimlendra
Shelby, Eugene M.
Shroff, Rajesh K.
Simpson, John B.

Slagle, Gregory S.
Slaton, G. Don
Sloand, Timothy Peter
Smith, Bruce L. Jr.
Smith, John W.

Smith, Phillip L.

Sorrels, John W.

Spiers, Jon P.

Springer, Melvin R. Jr.
Springer, William Y.

St. John, Greg
St. John, Melody
Stecker, Elton H. Jr.
Stecker, Rheeta M.
Stough, D. Bluford III
Tangunan, Priscilla L.
Tapley, David R.
Thomas, W. A1
Tucker, R. Paul
Vallery, Samuel W.
Vogel, Eric D.
Wagenhauser, Karl F.
Wallace, Thomas “Tom”
Walley, Luther R.
Warren, E. Taliaferro
Watermann, Eugene
Waters, Samuel
Webb, Timothy
Woodward, Philip A.
Wright, Charles C.

Yang, Leo
Young, Michael J.

Grant County

Heise, Brian A.

Irvin, Jack M.

Paulk, Clyde D.
Winston, Scott D.

Greene-Clay County

Baker, Clark M. #

Blair, Donald Waring

Boggs, Dwight F.

Bonner, J. Darrell
Brown, Howard Stanton
Bulkley, William J.
Burchfield, Samuel S.
Cagle, Roger E.

Clark, Frank
Collier, Jon D.

Crow, Asa A.

D’Anna, Richard E.
Duckworth, Hillard R.
Fonticiella, Adalberto
Hardcastle, R. Lowell
Hazzard, Marion P.
Hendrix, Barry
Hendrix, Lisa
Hobby, George A.

Ilyas, Mohammad
Kemp, Clarence
Lawson, J. Larry
Luker, Jerome H.
Mitchell, Bennie E.
Morrison, Jimmy J.
Muse, Jerry L.
Nissenbaum, Eliot M.
Page, Billie C.

Purcell, Donald I.

Rich, Cheryll Darline
Rouse, Kevin
Schechter, Ron D.
Shedd, Leonus L.
Sheridan, James G.
Shotts, C. Mack Jr.
Shotts, Vem Ann
Smith, Norman E.
Watson, Samuel D.
White, Robert B.
Williams, Dwight M.
Williams, Jacob M.
Wilson, John E.

Ziomek, Stanley

Hempstead County

Downs, Michael
Harris, Lowell O.

Holt, Forney G.

Opiela, Jaroslaw P.
Parcon, Paul J.

Stevens, David G.
Williams, Carl L.

Hot Spring County

Berry, Frederick B.
Bollen, A. Ray
Brashears, Larry B.
Burton, Bruce K.

Cobb, Russell W.

Ellis, C. Randolph
Kersh, N. B.

Mayfield, Robert
Purifoy, Shawn
Tilley, Absalom

Vaughan, John A.

White, Bruce A.

White, Robert H.
Willingham, Cynthia

Howard-Pike County

Chuadry, Zafar A.

Dunn, Robert
Floyd, Mark A.

Gullett, A. Dale
Humphreys, T. J. Jr.

King, Joe D.

Martinazzo-Dunn, Anna
Peebles, Samuel W.

Sayre, John
Sykes, Robert
Turbeville, James O.
Verser, Michael
Ward, Hiram T.

White, Phillip L.

Independence County

Alexander, William Steve
Allen, James D.

Angel, Jeff D.

Baker, J.R.

Baker, Robert V.

Barnes, Seth Michael
Bates, Ronald J.

Beck, James F.

Bernard, Douglas Dean
Bess, Lloyd G.

Brown, Hunter Lee
Brown, Verona T.
Cummins, Thomas
Davidson, Andy
Davidson, Dennis O.
Fielder, David
Fowler, William
Goodin, William H. Jr.
Hays, Sarah F.

Jeffrey, Jay R.

Johnson, Deborah A.
Jones, Edward J.

Jones, Edward T.

Joseph, Aubrey S.

Ketz, Wesley J.

Lambert, John S.

Lowery, Ronald
Lytle, Jim E.

McClain, Charles M. Jr.
Melton, Clinton G.
Montgomery, F. Renee’
Moody, Lackey G.

Moody, Melody
Neaville, Gregory
O’Brien, Marcus D.
Piediscalzi, Nicholas
Scott, John G.

Simpson, Ronald
Slaughter, Bob L.

Number 6

December 2000 • 21 1

Independence - Miller County

Arkansas Medical Society 2000 Membership Roster

Stanton Shields, Mary
Catherine
Sutterfield, Terry F.
Taylor, Chaney W.
Taylor, Charles A.
Thrasher, James R.
Waldrip, William J. Ill
Walton, Robert B.
Webster, Russell R
Williams, Robin C.

Jackson County

Ashley, John D. Jr. #
Calhoun, Aris
Chauhan, Mufiz A.
Dudley, Guilford M. Ill
Falwell, K. Wade
Frankum, Jerry M. Jr.
Green, Roger L.
Hergenroeder, PaulJ.
Hunt, Randall Evan
Jackson, Jabez Fenton Jr.
Jones, Karen Dee
Junkin, A. Bruce
Poon, Hon K.

Reynolds, Roland C.
Snodgrass, Phillip A.
Tan, Domingo

Jefferson County

Alexander, Lester T.
Ancalmo, Nelson
Anderson, Charles W.
Armstrong, Simmie Jr.
Atiq, Omar T.

Atkinson, Rohhie
Atnip, Gwyn
Attwood, H. M.

Bell, Carl H. Jr.

Bitzer, Lon
Bracy, Calvin M.

Brooks, R. Teryl Jr.
Broughton, Stephen A.
Buckley, J . Wayne
Buckner, Amy
Busby, John
Campbell, James C. Jr.
Carlton, Irvin L. #
Clark, Charles A.
Coleman, Roy D.
Crenshaw, John
Davis, Charles M.

Davis, Paul W.

Dedman, John D.
Deneke, William
Dharamsey, Shabbir A.
Duckworth, Thomas S.
Dunaway, Joseph D.
Fendley, Ann E.

Fendley, Herbert F.
Flowers, Martha A.
Forestiere, Lee A.

Frigon, Jacquelyn S.
Gardner, Dan R.

Garner, Kimberly
Gordon, Anthony
Green, Horace L.

Gullett, Robert R. Jr.
Harris, John E.

Harvey, Jerry L.

Holaday, Lisa M.

Hughes, L. Milton
Hussain, Shafqat
Hutchison, E. L.

Hyman, Carl E.

Irwin, Raymond A. Jr.
Jacks, David C.

Jacks, Dennis
James, William J.

Jenkins, Bobby
Jenkins, Mary Ellen
Jones, James III
Justiss, Richard D.

Kabani, Noor
Krupala, James Lee
Langston, Lloyd G.

Ligon, Ralph E.

Lim, William N.

Lindsey, James A.

Lum, Don
Lupo, David A.

Lytle, John O.

Mabry, Charles D.

Madera, George J.

Malik, Shamim A.

Marcus, Herschel
Marfatia, Vikram S.
McDonald, Robert L.
Meredith, William R.
Middleton, Toni L.

Miller, Donald L.

Miller, Joseph E.

Milligan, Monte C.
Mohiuddin, Mohammed J.
Morris, Gerald C.

Newan, Michael
Nixon, David T.

Nixon, William R.
Nuckolls, J. William
Over, Darrell R.

Pearce, Malcolm B.

Pierce, J. R. Jr.

Pierce, Reid
Pierce, Ruston Y.

Pollard, J. Alan
Quimosing, Estelita M.
Redman, Anna T.

Reid, Lloyene B.

Roaf, Sterling A.
Roberson, George V. Jr.
Robinson, Paul F.

Rogers, Henry L.

Ross, Robert L.

Samuel, Ferdinand K.

Sangoseni, Abiodun
Shorts, Stephen D.
Shrum, Kelly
Simmons, Calvin R.
Simpson, P. B. Jr.

Smith, Paul L.

Stern, Howard S.
Sullenberger, A. G.
Tejada, Ruben
Townsend, Thomas E.
Tracy, C. Clyde
Trice, James
Walajahi, Fawad H.
Washington, Erma
Wineland, Herbert L.
Worrell, Aubrey M. Jr. #

Johnson County

Goodman, James David
Kuykendall, Scott
McKelvey, Richard
Pennington, Donald H.

Lafayette County

Harbin, Bradley
Lee, Willie J.

Lawrence County

Davidson, Charles D.
Hughes, Joe E.

Joseph, Ralph F.
Lancaster, Shawn
Lancaster, Ted S.
Quevillon, Robert D.
Spades, Sebastian A. Ill
Vellozo, Paul

Lee County

Balke, Susan W.

Gray, Dwight W.

Ly, Duong N.

Ly, Phuong
Waddy, Leon Jr.

Little River County

Covert, George K.

Kile, H. Lawson Jr.
Kleinschmidt, Kevin C.
Vorhease, James W.

Logan County

Ahmed, Sahibzada
Alexander, Eugene
Borklund, Maurice K.
Buckley, Douglas A.
Daniel, William R.

Enns, Wayne P.
Harbison, James D.
Richey, Jason D.

Lonoke County

Abrams, Joe A.

Anderson, Leslie
Blair, Ruth Ann
Braswell, Thomas
Holmes, Byron E.

Inman, Fred C. Jr.

Merritt, James M.

Paslidis, Nick J.

Rochelle, Joe
Schumann, Gerald M.
Shurley, Floyd Jr.

Wycoff, Robert M.

Miller County

Alkire, Carey
Andrews, A. E. Jr.

Barnes, Walter C. Jr.
Bigongiari, Lawrence R.
Blankenship, D. Michael
Burns, Billy R.

Campanini, D. Scott
Carlisle, David L.

Dildy, Edwin V. Jr.

Ditsch, Craig E.

Dodd, N. Leland
Dodge, John M.

Duncan, Donald L.

Ford, John Suffern

Fox, Thomas

Franks, Hayden

Gabbie, Mark

Graham, John

Green, R. Clark

Griffin, Nancy

Hollingsworth, Charles E. II

Jean, Alan B.

Jones, John W.

Joyce, F. E.

Kittrell, James
Knowles, Stanley C.

Loe, Arlis W.

McGinnis, Robert S. Sr.
Morris, Howard
Norris, John A.

Peebles, Larry M.

Robbins, Joseph
Robertson, William J.
Rountree, Glen A.

Royal, Jack L.

Sarrett, James
Schmidt, Howard
Shipp, G. Carl
Smith, Arnett D. Jr.
Smolarz, Gregory J.
Solomon, J. Alan
Somerville, Patrick J.
Spence, Shanna
Stringfellow, Jerry B.

Stussy, Shawn
Thomas, Jeffory
Vereen, Lowell E.

Wade, Billy
Wilhelm, Frieda

212 • The Journal

Volume 97

2000 Arkansas Medical Society Membership Roster

Miller - Pulaski County

Wren, Herbert B.
Wright, Nathan L.
Yarbrough, Charles P.
Young, Mitchell

Mississippi County

Abraham, Anes Wiley
Abramson, Lawrence
Anderson, Laurie Jean
Bell, Mary C.
Biggerstaff, Jerry
Brock, Charles C. Jr.
Butler, Judith Arlene
Cullom, Sumner R.
Fairley, Eldon
Fergus, R. Scott
Hester, Karen Calaway
Hester, Richard
Hubener, Louis F.
Hudson, James H.
Husted, G. Scott
Jones, Herbert
Jones, Joe V.

Lin, Ching'Shan
LoCascio, Paul A.
Marcus, Trent Wright
Osborne, Merrill J.
Pollock, George D.
Rhodes, Joseph
Rodman, T. N.

Russell, James D.
Shahriari, Sia
Shaneyfelt, E. A.
Smith, Ronald D.
White, John S.
Williams, John S.

Monroe County

Campos, Amador
Collins, Linda
David, Neylon C. Jr.
Pham, Dac Tat
Pupsta, Benedict F.
Stone, Herd E. Jr.
Walker, Walter L. #

Ouachita County

Abbott, Judy
Blagdon, Donald G.
Braden, Lawrence F.
Brunson, Milton
Crump, Mark R.
Daniel, William A.
Dedman, William D.
Floss, Robert
Fohn, Charles H.
Guthrie, James
Hartman, Raymond P.
Hout, Judson N.
Jameson, John B. Jr.
Kelly, Patricia
Kendall, Jerry R.

Martin, Dan
McFarland, Gale
Mosley, David
Nunnally, Robert H.
Ozment, L. V.

Shrestha, Bal Narayan
Thorne, Arthur E.

Phillips County

Athota, Prasad J.

Barrow, John H. Jr.

Bell, L. J. Patrick
Bell, L. J. Patrick II
Berger, Alfred A.#

Epstein, S. Mitchell
Faulkner, Henry N.
Frederick, William Ronald
Hall, Scott

McCarty, Gordon E. Jr.
McDaniel, Marion A.
Miller, Robert D. Jr.

Paine, William T.

Patton, Francis M.
Rangaswami, Bharathi
Rangaswami,
Narayanaswami
Reddy, Vijayabhasker
Tukivakala, P. Reddy
Vasudevan, Kanaka
Vasudevan, P.

Webber, David L.
Winston, William II
Wise, James E. Jr.

Polk County

Beckel, Ron Jr.

Finck, John Henry
Fried, David D.

Henning, Theodore J.
Lamb, Johnny Mack
Lochala, Richard
Mesko, John D.

Perry, Karen A.

Sosa, Humberto J.

Tinnesz, Thomas
Wood, John P.

Pope County

Allison, Russell
Ashcraft, Ted
Austin, Nathan
Bachman, David S.

Barron, William G.

Barton, A. Dale
Battles, Larry D.

Beavers, H. Kevin
Bell, Michael
Bell, Robert A.

Berner, Dennis W.

Birum, Patricia J.

Bradley, Stanley C.

Brown, Charles H.

Brown, William Bruce
Burgess, James G.
Callaway, Jody C.

Carter, James M.

Cloud, Joe A.

Crouch, James Jr.
Crumpler, Joe B. Jr.
Duffield, Robin P.

Dunn, Donald L.

Ewing, Donald C.

Ezell, Gerry D.

Ferris, Craig A.

Galloway, William W.
Gately, Stanley
Haines, Lynn
Hale, Jeffrey
Harden, V. Anthony
Harrison, Rick
Henderson, Vickie L.
Hendren, Mike
Hill, Donald F.

Hines, Cynthia R.
Honghiran, Ted
Johnson, Carroll
Jones, Charles Jr.

Kerin, Douglas
Khan, Muhammad A.
Killingsworth, Stephen M.
King, John W.

King, W. Ernest Jr.

Kolb, James M. Jr.

Kriesel, Ben J.

Lawrence, Frank M.

Lee, John R.

Lovell, Richard K. Sr.
Lowrey, Douglas H.
Lowther, Laura Marie
Luzietti, Nicholas P.
Massey, V. Rudolph
Mauch, E. Jane
May, Robert H. Jr.
McCraw, Barry W.

Meyer, Kelly H.

Monfee, Andrew M.
Murphy, David S.

Myers, Gary Dean
Myers, J. Mark
New, Kenneth O.
Pilkington, Neylon S.
Price, Larry
Richison, George C.
Riddell, C. Michael
Riley, Don C.

Smith, Lynette
Sosebee, William S.

Soto, Sergio F.

Stolz, Gerald A. Jr.

Tapley, Thomas S.

Teeter, Stanley D.

Thurlby, W. Robert
Turner, Finley P. II
Turner, Kenneth B.

West, Boyce W.

White, Ronald
Wilkins, Charles F. Jr.
Williams, David M.
Williams, Thomas C.
Young, Charles

Pulaski County

Abel, Lee C.

Abraham, Dana C.
Abraham, James H. Ill
Abraham, James H.
Ackerman, William E. Ill
Adametz, James
Adametz, John Sr.
Adametz, John Jr.
Adametz, Kimberly
Adams, Christopher
Adamson, James
Alexander, Albert S.
Alford, T. Dale #

Allen, Durward Jr.

Allen, John E. Jr.

Alston, Phillip
Angtuaco, Edgardo
Angtuaco, Edward E.
Aquino, A1
Araoz, Carlos
Archer, Robert L.
Arrington, Robert
Atha, Timothy C.
Atkinson, Evangelina
Baber, John C.

Baber, John T.

Bailey, H. A. Ted Jr.
Baker, Glen F.

Baker, John W.

Baker, Johnson
Baldwin, Maxwell R.
Baldwin, Shelly
Baltz, Brad Patrick
Baltz, Katherine
Barber, Jeffrey
Barber, Laurie
Bard, David S.

Barger, Denver L.

Barlow, Brian E.

Barnes, C. Lowry
Barnes, Reginald
Barnes, Robert W.
Barnett, David
Barron, Edwin N. Jr.
Barrow, Robert
Bartnicke, Benjamin J.
Barton, Gary
Baskin, Barry
Bates, Joseph H.

Bates, Ramona L.

Bates, Stephen
Bauer, David
Bauer, F. Michael
Bauer, Frank M. Jr.

Number 6

December 2000 * 213

Pulaski County

Arkansas Medical Society 2000 Membership Roster

Bauman, David C.

Bayliss, John M.

Beadle, Beverly
Bearden, James R.

Beaton, J. Neal
Beau, Scott
Beck, Joseph II
Becquet, Norhert J.
Belknap, Melvin L.

Bell, Rex H.

Bennett, Anita
Bennett, F. Anthony Jr.
Benton, William
Berry, Robert L.

Bevans, David III
Bevans, David W. Jr.
Bienvenu, Gregory
Bienvenu, Harold G. Ill
Bierle, Michael
Billie, James
Biondo, Raymond V.
Birkett, Ian McRae
Bishop, William B.
Blackshear, Jack L. Jr.
Blankenship, William F.
Blasier, R. Dale
Boehm, Timothy
Boellner, Samuel W.

Boger, James E.

Boop, Bradley Scott
Boop, Warren C. Jr.
Bornhofen, John H.

Bost, Roger B.

Bourne, David E.

Bowen, Timothy
Bowen, W. Scott
Bower, Charles M.

Boyd, Charles M.
Bradbum, Curry B. Jr.
Bradford, J. David
Bradley, Joe F.

Brainard, Jay O.

Breau, Randall L.
Bressinck, Renie E.

Brewer, Robert
Brimberry, Ronald K.
Brineman, John
Brinkley, Roy A.

Brizzolara, A. J.

Brizzolara, John Paul
Broach, R. Fred
Broadwater, John Ralph Jr.
Brown, Michael
Brown, Pamela S.

Brown, Randel
Browning, Donald G.
Browning, Stanley K.
Bruce, Thomas A.

Bruffett, Wayne L.

Bryan, James W. IV
Buchanan, Francis R.
Buchanan, Gilbert A.

Buchman, Joseph K.
Bucolo, Anthony P.
Buford, Joe L.

Burba, Alonzo R.

Burger, Robert A.

Burks, Karen
Burnett, Hugh F.
Burrow, Dennis R.
Bursey, Deborah Lee
Byrum, Jerry
Calcote, Robert A.
Calderon, Vincent Jr.
Caldwell, Charles R.
Calhoon, J. Dale
Calhoun, Joseph D.
Calhoun, Richard A.
Campbell, Gilbert S.
Campbell, James W.
Caplinger, Kelsy J. Ill
Carfagno, Jeffrey
Carle, Scott W.

Carson, Layne E.

Carter, Jerry L.

Carttar, Charles
Caruthers, Carol
Caruthers, Samuel B. Jr.
Casali, Robert E.

Cash, Darlene
Casper, Robert B.
Casteel, Helen
Cate, Chris M.

Cathey, Janet
Cathey, Steven
Chakales, Harold H.
Chandler, Kay H.
Chappell, Carol W.
Chatelain, Stephen M.
Cheairs, David B.
Cheairs, John T.
Chesser, Michael Z.
Chisholm, Dan P.
Choate, Robert B.
Christian, John D.
Christy, George W.
Chudy, Amail
Church, Marion M.
Clark, Richard B.

Clark, Robert B.
Cleveland, Elton
Clift, Steven A.

Clifton, Cliff
Clogston, Charles W.
Cobb, Jock S.

Cockrill, H. Howard Jr.
Colclasure, Joe B.
Collins, David
Collins, Gary James
Collins, Kevin J.
Colwell, Karen Louise #
Cone, John
Cook, J. Mitchell
Cook, Timothy R.

Cooper, Keith W.
Cope, Michael
Corbitt, Mary
Cornell, Paul J. #
Courtney, Willis Jr.
Coussens, David M.
Covey, M. Carl Jr.
Crews, J. Travis
Crocker, Charles H.
Cross, J. B.

Crow, Joe W.

Crow, R. Lewis Jr.
Darwin, William G.
Daugherty, Joe D.
Daugherty, John L.
David, Alex
Davie, Melanie
Davila, David G.
Davis, J . Lynn
Davis, Scott A.

Day, James A.

De Bruyn, Van H.
DeLoach, John Jr.
Dean, David M.

Dean, David P.

Dean, Gilbert O.
Deaton, C. William Jr.
Deed, Ashley
Deer, Philip J. Jr.

Deer, Philip James III
Delap, Susan
Dennis, James L.
DesLauriers, S. Killeen
Dickins, John R. E.
Dickins, Robert D. Jr.
Dillard, Daniel C.
Diner, Bradley
Dixon, Keith A.

Dodd, Doyne
Domon, Steven E.
Doucet, Marlon J.
Douglas, Warren M.
Downs, Ralph A.
Driskill, Angela
Duke, Anton L.
Dungan, William T.
Dunnagan, Steven A.
Dwyer, Gregory A.
Eans, Thomas L.

Easter, Rex M.

Edge, Otis H.
Edmiston, Frank G.
Edwards, Louis Jerry
Eisenach, R. Jeffrey
English, Jim
Evans, Billy
Evans, Samuel C.
Farmer, Joseph F.
Farque, Greg L.

Fasules, James
Fenton, Ronnie M.
Ferguson, Max Ann

Fernandez, Agustin
Ferris, Ernest J.

Fewell, Ronald D.
Fielder, Charles R.
Finan, Barre F.

Fincher, Robert L.

Fiser, Martin
Fiser, Robert H. Jr.

Fiser, William P. Jr.
Fitzgerald, Charles
Fitzhugh, A. Stuart
Flamik, Darren E.
Flaming, Jay
Fletcher, Anthony
Fletcher, Thomas M.
Florez, James P.

Floyd, Bill G.

Ford, Barry G.

Foster, Gil
Fraiser, Lacy P.

France, Gene L.

Fraser, Eric A.

Fravel, Jonathan F.
Frazier, Cynthia
Frazier, G. Thomas
Freeman, Diane
Fuller, C. Dale
Fuller, C. James III
Fulmer, John M.
Galbraith, Robert C.
Gardner, Guy F.

Garner, William L.
Gehl, Jerome
Gettys, Joseph M. Jr.
Gibbs, Mark
Gibson, Gordon L.
Giglia, Anthony R. Ill
Giles, Wilbur M.
Gillespie, A. Tharp
Gillespie, John Newton
Gilliam, David
Gist, Charles C.

Glasco, Gerry B.

Glenn, Wayne B.
Glover, Lawson E. Jr.
Glover, W. Clyde
Golden, William E.
Goldsmith, Geoffrey
Gosser, Bob L.

Goza, Gary R.

Goza, George M. Jr.
Graham, Donna M.
Graham, Richard
Grant, Karen G.

Green, Benny J.

Green, Cheryl
Greenway, C. Don
Greenwood, Denise R.
Greer, G. Stephen
Greutter, John E. Jr.
Griebel, Jack A. Jr.
Griffin, David

214 • The Journal

Volume 97

2000 Arkansas Medical Society Membership Roster

Pulaski County

Grimes, H. Austin
Guard, Peggy K.
Guggenheim, Frederick G.
Guin, Jere D.

Hagler, James L.

Hahn, Herbert L.

Hall, A. D.

Hall, A. David
Hall, Gregory S.

Hall, R. Whit
Hamilton, George Jr.
Hampton, John R. Ill
Hankins, Edwin III
Hanna, Ehab
Harber, Harley
Hardberger, R. E.

Hardin, Robert
Hardin, Ronald D.

Harger, C. Harold
Hargrove, Joe L.

Harms, Steven E.

Harper, Gary E.

Harrell, James Jr.
Harrendorf, Cagle
Harrington, G. Scott
Harrington, Mariann
Harris, Donald R.

Harris, Nita
Harris, T. Stuart
Harris, W. Turner
Harrison, A. Vale
Harrison, Roy E.

Harrison, William
Harshfield, David Lee Jr.
Hart, Thomas M.

Harter, Scott
Hatch, Allan B.

Hathcock, Stephen A.
Hauer-Jensen, Martin
Hayden, William F.

Hayes, J. Harry Jr.

Hayes, John
Hayes, Richard L.

Hayes, Sidney P.

Haynes, W. Ducote
Headstream, James W.
Hearnsberger, H. Graves III
Hearnsberger, Henry G. Jr.
Hearnsberger, John E.
Heaton, Keith M.

Hedges, Harold IV
Hedges, Harold H.

Hefley, Bill F. Sr.

Hefley, William F. Jr.
Heifner, John K.

Henker, Fred O. Ill
Henry, C. Reid Jr.

Henry, D. Andrew
Henry, G. Michael
Henry, G. Morrison
Henry, J. Charles
Henry, J. Forrest Jr.

Henry, Richard Y.

Henry, W. Bradley
Henry, William T.

Herring, Grady Jr.

Herron, Jerry M.

Hickey, Joseph P.

Hicks, David C.

Hicks, David L.

Hixson, Marcia Lynn
Hodges, J. Timothy
Hoffmann, Thomas H.
Holland, Jay D.

Holloway, J. Douglas
Holt, Stephen
Holton, Jerry C.

Hopkins, Karmen
Horn, Thomas Dag
Hough, Aubrey J. Jr.

Houk, Richard
Houston, Samuel
Howell, Coburn S. Jr.
Hubach, Cindy
Hudec, Regina
Hughes, Ronald D.
Hundley, Randal F.
Hutchins, Laura
Hutchins, Steven W.
Hutson, Harold G.

Ibsen, Michelle J.

Ingram, Jim
Ironside, J. Brett
Jackson, J. Presley
Jackson, Richard J.

Jansen, G. Thomas
Jenkins, Bradley
Johns, Richard D.

Johnson, Anthony D.
Johnson, B. Richard
Johnson, Ben D.

Johnson, Carl
Johnson, Clifton R.
Johnson, Dianne Flowers
Johnson, M. Bruce
Johnson, Philip H.
Johnston, Dale E.
Johnston, Kenneth
Jones, Gail Reede
Jones, Garry L.

Jones, John C.

Jones, Robert D.

Jones, Roy Steven
Jones, S. Michael
Jones, William N.

Jordan, F. Richard
Jordan, Randy A.

Joseph, Ralph F. II
Joseph, William Frank
Jouett, W. Ray
Joyce, John W.

Junkin, Ruth H.
Kaemmerling, Raymond E.
Kagy, Lori Michelle

Kagy, Matthew
Kahn, Alfred Jr.

Kane, James J.

Karageanes, Steven
Keeran, Michael G.

Keith, Sharon C.

Kellar, Stanley L.

Keller, Alfred W.
Kennedy, Eleanor E.
Kennedy, H. Frazier
Kennedy, Robert
Keplinger, Florian
Ketcham, Jeffrey
Key, J. Michael
Kidd, Tracy L.

Kilgore, Erik J.

Kilgore, Reed W.

King, Michael T.

King, W. David
Kiser, Thomas
Kittler, Fred J.

Kizziar, Jim C.

Klimberg, V. Suzanne
Knott, Patricia A.

Knox, Michael F.

Kolb, Agnes J.

Koonce, Thomas W.
Kovaleski, Thomas M.
Krulin, Gregory S.

Kuhn, Ronald
Kulik, Steven A.
Kumpuris, Andrew G.
Kumpuris, Frank G.
Kusenberger, Don Levi
Kyser, J . Floyd
Laakman, Robert W.
Lambert, Robert A.
Landers, James H.

Lane, John W.

Lang, Nicholas P.
Langford, Timothy
Lawton, Andrew William
Lehmberg, Robert W.
Leibovich, Marvin
Leithiser, Richard Jr.
Leonard, Donald G.

Leou, Frank J.

Lewis, Derek
Lile, Henry A.

Lincoln, Ben M.

Lipke, Jay M.

Loebl, Edward C.

Logan, Charles W.
Lomax, Lorene
Love, Tommy L. Jr.

Lowe, Betty A.

Lu, Eugene
Lucy, Vincent
Ludwig, Frank R.

Luttrell, Rex E.

Lyle, Carlene W.

Lyons, Virgle E. Jr.

Ma, Frank
Mabrey, William
Magie, Stephen K.

Mallory, John A.

Maloney, F. Patrick
Maners, Ann
Markland, Gary S.

Marks, Stephen R.

Marotti, A. Scott
Martin, Kenneth A.
Marvin, Peter
Mason, J. Zachary
Mason, William L.
Matthews, Joseph W.
McCarthy, Richard E.
McCasland, Leslie D.
McConnell, John D.
McCoy, Julia M.
McCracken, Gail Ann
McCracken, John
McCrary, George A.
McDonald, James E.
McDonald, Judy
McGhee, Judith E.
McGhee, Michael A.
McGowan, Robert Jr.
McGrew, Robert N.
McKelvey, K. David
McKnight, C. Allen
McLaughlin, Shannon
McLeane, Mark
McNee, Valerie
Meacham, Donald F.
Meador, Annette Parker
Meadors, Carol
Meadors, Frederick
Meadors, John
Medlock, Rickey D.

Mego, David Michael
Mellor, Roy II
Melton, Christopher
Mendelsohn, Lawrence A.
Merritt, Mathew
Meziere, Tom
Miles, David A.

Miller, Forrest B. Jr.

Miller, Michael
Miller, Raymond P. Sr.
Milligan, L. Beth
Milner, E. L.

Mitchell, George K.
Mitchell, Katherine B.
Mizell, Philip
Mizell, Walter S.

Moffett, T. Robert Jr.
Money, Wandal D.
Montanez, Josue
Mooney, Donald K.
Moore, Burton A.

Moore, J. Malcolm Jr.
Moore, Michael
Moore, Rex N.

Number 6

December 2000 • 215

Pulaski County

Arkansas Medical Society 2000 Membership Roster

Moore, Robert B.
Moore, Thomas C.
Morris, Barbara
Morris, W. Dale
Morrison, Debra F.
Morse, James C.
Morton, William J.
Mulhollan, James S.
Murphy, Bruce
Murphy, Jeanne
Murphy, Randolph
Murphy, Robert
Murphy, Tena
Nagel, Fred G.

Nair, Balan A.
Napolitano, Charles A.
Nash, John C.

Nelson, Alvah J. Ill
Nelson, Carl L.
Newbern, D. Gordon
Newsum, Jon Kirby
Newton, Fred E.
Nguyen, Duong
Nichols, Sandra D.

Nix, Richard A.

Nokes, Steven
Norton, George A.
Norton, J.B. Jr.

Norton, Joseph A.
Nowlin, James Bill
Nugent, Richard
Nutt, Angela
O’Neal, James Franklin
Ochoa, Eduardo R. Jr.
Oddson, Terrence A.
Oglesby, Walter R.
Osam, Patrick N.
Overacre, Robert
Owen, Kip
Owen, Richard Jr.
Owings, Richard
Padberg, Frank T.
Paddock, George
Padilla, Fernando
Palmer, Hal
Pappas, James J.
Parham, David M.
Parker, J. Mayne
Parker, Ray K.
Parkhurst, James
Parmley, Tim
Parnell, Clifton L. Ill
Pastor, Randy
Patel, Kamal
Patrick, Larry L.

Paulus, Thomas E.

Peal, Gabriel M.
Pearce, Charles E.

Peek, Richard
Peeples, R. Earl
Perser, Elwyn
Peters, John E.

Peters, Phillip J.

Petrus, Gary M.
Petursson, Gissur J.
Pevahouse, Joe
Phillips, Charles E.
Phillips, Hannah
Phillips, John D.

Pierce, William
Pike, John D.

Pledger, Norman R.
Pollard, Arlee E.

Pollock, Michael Marion
Pope, Christopher H.
Pope, Norton A.

Porter, Robert A. Jr.
Potts, Jerry L.

Power, Robert C.

Prather, Jerry L.

Pringos, Andrew A.
Pruitt, Tad
Pyle, Hoyte R. Jr.

Pyne, Jeffrey M.

Quinn, Brian D.

Ransom, John M.

Rapp, Richard J.

Raque, Carl J.

Rayburn, Samuel T.
Rector, Nancy F.
Redding, Allen H.

Reddy, Yeshwant
Reding, David L.
Redman, John F.

Reed, Ewing C. Jr.

Reese, William G.

Reid, Gene W.

Remmel, Raymond
Rice, James Curtis
Rice, Robert L.

Riddle, John F. Jr.

Riley, William H.
Ritchie, Robert Ross
Robbins, Kenneth
Roberson, Michael C.
Roberts, Kevin
Rodgers, C. Dudley
Rodgers, Charles H.
Rogers, Rachel M.
Roman, Anthony
Rooney, Thomas P.
Rosenbaum, Carl A.
Ross, Ashley Sloan
Ross, Cynthia
Ross, S. William
Rounsaville, Harry L.
Roy, F. Hampton
Rozas, David
Ruddell, Deanna N.
Ruggles, Dwayne L.
Russell, Anthony E.
Ryals, Rickey O.

Saer, Edward H. Ill
Safman, Bruce L.

Sanders, Kelli Keene
Sanderson, M. Bruce
Sangster, Michael
Santoro, Ian H.

Satre, Richard W.
Schlesinger, Scott Michael
Schock, Charles C.
Schratz, Bruce E.
Schroeder, George T.
Schultz, Charles E.

Schultz, John C.
Schwander, L. Howard
Schwankhaus, John D.
Scott, Jane F.

Scruggs, Jan W.

Searcy, Robert M.

Seguin, Rosey
Seibert, Robert
Selakovich, Walter G.
Sessions, Louis II
Shaw, Robert Haley
Shewmake, Kristopher B.
Shields, Eddie
Shock, John P.

Shock, Melessa
Short, Harold K.

Shotts, Joseph
Shrieve, Dennis Charles
Shuffield, James
Siems, Martin
Silvoso, Gerald R.

Silzer, Robert R.

Simmons, Debra Lynn
Simmons, Orman W.
Simpson, Steve
Sims, James M.

Singer, Peter
Singleton, L. Gene
Sipes, Frank M.

Sitarik, Kathleen
Sitz, Karl V.

Skokos, C. Kemp
Slater, John G. Jr.

Slaven, John E.

Slayden, John E.

Sloan, Eugene E.

Sloan, Fay M.

Smart, Douglas F.

Smelz, Johnny
Smith, Aubrey C.

Smith, Charles W.

Smith, David E.

Smith, Douglas B.

Smith, G. Richard Jr.
Smith, J. Tom
Smith, James L.

Smith, Melanie Herrold
Smith, Purcell Jr.

Smith, Samuel D.

Smith, Thomas J.

Smith, Thomas W.

Smith, Vestal B. Jr.

Snyder, Douglas Scott
Snyder, Victor F.

Somers, A. Jack Jr.
Sorrells, R. Barry
Sotomora, Ricardo F.
Squire, Arthur E. Jr.

St Amour, Thomas E.
Stair, J. Michael
Stallings, James Walt
Stanley, Joe P.

Stefans, Vikki Ann
Stephens, Wanda
Stem, Scott J.

Sternberg, Jack J.
Stewart, Bobby Ray
Stewart, Daryl
Stinnett, Thomas
Stokes, B. Douglas
Storeygard, Alan R.
Stotts, John R.

Stout, Kimber
Stout, Michael D.
Strauss, Mark A.

Stringer, Warren
Strode, Steven W.
Stroope, George F.
Studdard, James D.
Sturdivant, Stephen
Suen, James
Sullivan, Charles D.
Sullivan, Jan R.
Sundermann, Richard H.
Suphan, Neema A.
Talbert, Gary Eugene
Talbert, Michael L.
Tamas, David E.

Tanner, James A.

Taylor, David R.

Taylor, Eugene H.

Taylor, Ken M.

Taylor, Martin A.
Tedford, John G.

Tharp, John G.

Thomas, A. Henry
Thomas, Peter O.
Thomason, Steven L.
Thompson, S. Berry Jr.
Thorn, G. Max
Tilley, Steve
Tolleson, Claudia
Towbin, Eugene J.

Tracy, Phillip A.

Tranum, Bill L.

Trigg, Laura
Tseng, Jyi-Ming
Tucker, R. Stephen
Tucker, W. Everett
Valentine, Robert G. Jr.
Van Zandt, Janelle
Velez, Duane
Vinsant, Kurtis
Vogel, Robert G.

21 6 • The Journal

Volume 97

2000 Arkansas Medical Society Membership Roster

Pulaski - Sebastian County

Wade, William I. Jr.
Wagoner, Jack
Walker, Lee
Walker, Ronald
Walt, James R.

Waner, Milton
Ward, Harry P.

Ward, Thomas
Washington, Mitzi A.
Watkins, Charles J.
Watkins, John Jr.
Watkins, John G. Ill
Watkins, Julia
Watkins, Larry S.
Watson, Daniel W.
Weber, Edward R.
Weber, Michael
Weiss, David W.

Weiss, Gerald N.

Welch, Samuel Bradley
Wellons, James A. Jr.
Wende, Raymond A.
Wenger, Carl E.

West, Joseph
Westbrook, Kent C.
Westbrook, September
Westerfield, Frank M. Jr.
Westerfield, Robert
Westfall, Christopher T.
Whiteside-Michel, Julia
Wilcox, Linda G.
Wilkes, Elbert H.
Wilkes, T. David I.
Williams, Alonzo D.
Williams, C. David
Williams, G. Doyne Jr.
Williams, Paul E.
Williams, Ronald N.
Williamson, Adrian III
Wills, Pamela
Wilson, Elaine
Wilson, Frances C.
Wilson, Frank J. Jr.
Wilson, I. Dodd
Wilson, James W.
Wilson, John L.
Wolverton, John
Workman, W. Wayne
Worley, Linda
Wortham, Thomas H.
Wyatt, D. Neal
Wyatt, Richard A.
Wylie, Paul
Yamauchi, Terry
Yeager-Bock, Angy
Yee, Suzanne
Yocum, John
Young, Douglas E.
Young, Evelyn
Zelnick, Paul
Ziller, Stephen A. Ill

Randolph County

Baltz, Albert L.

Barre, Hal S.

DeClerk, Thomas
Guntharp, George
Hall, Jeffrey
Holt, Danny B.

Jansen, Andrew J. Ill
Smith, Norman K.
Troxel, Roger
Warner, Robert L. Jr.

Saline County

Albey, Mark
Baber, Quin M.

Baka, John V.

Beard, Michael R.
Bethel, James
Boyle, Ronald H.
Brashears, Clay
Burton, Charles R.
Caldwell, David L.
Cartaya, Daniel I.

Cash, Ralph D.

Cathcart, Evelyn
Coker, S. Dale
Cooper, James B.
Council, Robert A. Jr.
Dixon, Jerry W.

Dockery, Melissa
Duncan, J. Shelby
Eaton, James M.
Enderlin, Annette
Harper, Donald
Higginbotham, Michael
Hill, Edward B.

Hill, Howell V.

Hogue, F. Paul
Kirk, Marvin N. Jr.
Martindale, J. L.
Martindale, Mark A.
Pandit, Sudhir K.

Quade, Deborah
Ramsay, Rex C. Jr. #
Schally, Gordon R.
Schmidt, Michael J.
Stanford, Royce Allan Jr.
Steele, William L.
Sudderth, Brian F.
Taggart, Sam D.
Thibault, Frank G. Jr.
Thomas, Bill R.

Thorn, Harvey Bell Jr.
Tilley, Roger L.

Ulmer, Stacy L.

Vice, Mark
Viner, Donald L.

Wagner, Taylor
Watson, Kirk D.

Wright, John D.

Sebastian County

Acklin, Jimmy D.

Aclin, Richard R.
ALGhussain, Emad A.M.M.
ALRefai, Fareeda Ann
Albers, David G.

Alberty, Joe
Aldrich, Joseph
Anderson, Paul
Armstrong, Sinclair Jr.
Asbury, Dale W.

Atkins, Jimmie G.

Axelsen, Nils K.

Bailey, Charles W.

Baker, Max A.

Balsara, Zubin
Barr, Marilyn
Barton, Lance W.

Basinger, Norma Smith
Beachy, Allen L.

Bean, Paul E.

Beene-Lowder, Hannah L.
Berryhill, Richard E.
Berumen, Mike
Bise, Roger N.

Bodiford, Gary L.

Bordeaux, Ronald A.
Bouton, Michael S.

Bradford, A. C.

Brown, Byron L.

Brown, James A.

Brown, Richard N.

Buie, James H.

Builteman, James L.

Burks, Deland
Busby, J. David
Bylak, Joseph Andrew
Cain, Martin W.

Callaway, Michael
Capocelli, Anthony L.
Carson, Randall L.

Cassady, Calvin R.

Chalfant, Charles
Chapman, Robert K.
Chester, Robert L.

Cheyne, Thomas
Choby, Beth A.

Christopher- Harmon, Pamela
Coffman, Edwin L.

Coffman, John L.

Coleman, Michael D.

Craft, Charles
Crow, Neil E. Jr.

Culp, William C.

Davenport, O. Leo
De La Rosa, Raymond E.
Deaton, John M.

Deneke, James S.

Diment, David D.

Dorzab, Joe H.

Drolshagen, Leo F. Ill
Dudding, William F.

Eckes, Anne Michelle
Edstrom, Steven M.
Edwards, Gary
Ellis, Homer G.

Ennen, Randy
Espina, Dario Manuel
Farris, Paul E.

Feder, Frederick P. Jr.

Feild, T. A. Ill
Felker, Gary V.

Ferrell, Jeffrey
Fisher, Robert D.

Flanagan, A. Dean
Flanagan, Mary Clare
Fleck, Randolph Peter
Fleck, Rebecca
Flippin, Tony A.

Floyd, Charles H.

Floyd, Jeffrey Denton
Francis, Darryl R. II
Gaby, Cecil Walter
Gardner, Kenneth
Cast, Kristie L.

Gedosh, Edgar A.

Gill, James A.

Gills, Edward Larry
Girkin, R. Gene
Glendenning, Charles C.
Glover, D. Bruce
Gold, Adam
Goodman, R. Cole Jr.
Goodman, Raymond C. Sr.
Griggs, William L. Ill
Gwartney, Michael P.
Hamilton, Lance
Hanley, Larry L.

Haraway, Stuart D.

Harreld, Myra A.
Harrington, Paul T.
Hendrickson, Jon
Henry, James
Herren, Adrian L.

Hewett, Archie L.

Hinkle, Richard A. Jr.
Hoffman, John D.

Hoge, Marlin B.

Holder, Keith Franklin
Holmes, Williams C. Jr.
Hornherger, Evans Z. Jr.
Howell, James T.

Howell, Paul K. Jr.

Hughes, Robert P. Jr.
Huskison, William T.
Ibrahim, Manar S.A.
Ihmeidan, Ismail H.
Ingram, Ralph N.

Irwin, Peter J.

Jackson, Hugh H.

Jaggers, Robert
James, Arthur M.

Janes, Robert H. Jr.
Johnson, Arthur M.

Number 6

December 2000 * 217

Sebastian ■ Union County

Arkansas Medical Society 2000 Membership Roster

Jones, Greg T.

Kannout, Fareed
Kareus, John L.

Kelly, James E. Ill
Kelly, Thomas C.
Kelsey, J . F.

Keyashian, Mohsen
Kientz, John Jr.
Klopfenstein, Keith
Knox, Robert
Kocher, David B.
Koenig, Albert S. Jr.
Kradel, R. Paul
Kraemer, Soren R.
Kramer, Ralph G.
Kutait, Kemal E.

Kyle, W. Lamar
Lambiotte, Louis O.
Landherr, Edwin
Landrum, Samuel E.
Lane, Charles S. Jr.
Laws, Casey
Lee, Kent
Lenington, Jerry O.
Lewis, George L.

Lilly, Ken E.

Lilly, Kenneth E. Jr.
Little, Charles
Lockwood, Frank M.
Long, James W.

Loyd, Gregory M.
MacDade, Albert D.
Magness, Jack L. Jr.
Manus, Stephen C.
Mapes, Raelene Ann
Marsh, Michael A.
Martimbeau, Claude
Martin, Art B.

Martin, Maurice
Masri, Hassan M.
McCarty, Joseph
McClain, Merle
McClanahan, J. David
McEwen, Stanley R. #
McMinimy, Donald #
Miller, Robert C.
Miller, Robert M.
Miller, Shawn S.

Mings, Harold H.
Moore, Trudy J.
Moore-Farrell, Laura
Mosley, Myra C.
Moulton, Everett C. Jr.
Moulton, Everett C. Ill
Mumme, Marvin E.
Musick, Stanley C.
Muylaert, Michel
Nassri, Louay K.
Nelson, Steve B.
Nichols, David R.
Nolewajka, Andre J.
O’Bryan, Robert K.

Olson, John D.

Orten, Steven S.

Paris, Charles H.

Parker, Joel E. Jr.

Parker, Thomas G.
Passmore, Ann Kay
Pearce, Larry W.

Pence, Eldon D. Jr.
Pham, Thuylinh H.
Phillips, Don
Phillips, Kevin Clark
Pillstrom, Lawrence G.
Poe, McDonald Jr.

Poole, M. Louis
Post, James M.

Prewitt, Taylor A.

Price, Claire
Price, Lawrence C.
Rabideau, Dana P.

Raby, Paul L.

Rainwater, Melissa C.
Raymond, Thomas H.
Retz, Jacy
Rivera, Ernesto
Robinson, Ronald P.
Romero, Alfred T.
Russell, Debra
Russell, Rex D.

Sanders, Robert E.
Sanders, Robert V. III.
Saviers, Boyd M.
Schemel, William H.
Schkade, Paul A.
Schmitz, James
Schwarz, Julio
Schwarz, Paul R.
Seffense, Stephen J.
Seiter, Kenneth
Severns, Cyril
Sherrill, William M. Jr.
Short, Bradley Mark
Smith, Gerald P.

Smith, Kent
Smith, Steven Olin
Smith, Terrald J.

Snider, James R.

Stewart, Casey D.
Stewart, Jerry R.
Stewart, John B.
Stillwell, Mark
Sutterfield, Vikki L.
Swicegood, John R.
Tacoronti, Rudolph V.
Taft, Eileen
Taft, Eric
Teeter, Mark
Thompson, Robert J.
Turner, William F.

Van Asche, Christopher
Vanderpool, Roy E.
Vernon, Rowland P. Jr.
Waack, Timothy

Wallace, Kenneth K.
Wanker, Frank L.

Webb, William K.

Weisse, John J.

Wells, John D.
Westermann, Norman F.
Whitaker, John
Wikman, John H.

Wills, Paul I.

Wilson, Morton C.
Wolfe, Michael S.

Woods, Leon P.

Zufari, Munir M.

Sevier County

Buffington, Mike
Devlin, Terri A.
Gonzalez, Floyd
Hoyt, Jonathan
Jones, Charles N.

Jones, Thomas
Richards, Juan Carlos
Stearns, David E.

St. Francis County

Collins, E. Morgan Jr.
Conner, George
Fong, Fun Hung
Kumar, Sudhir
Matthews, Seniora
Meredith, James Jr.

Miller, Matthew W.
Patton, W. Curtis
Schwartz, Frank R.

Tri County

(Sharp, Izard, Fulton)

Arnold, Carl
Bozeman, Jim G.

Campos, Louis
Dibrell, Fredrick
Gamer, Julea
Grasse, A. Meryl
Hennan, Floyd A.
Jackson, George W.
Krygier, Albin J. #

Lane, Robert C.

Mayfield, Michael
Moody, Michael N.
Phillips, Rebecca
Relyea, William V.

Sitzes, David Alfred
Sra, Surinder
Tatum, Harold M.

Tucker, Charles L.

Varela, Charles D.
Williams, Robert S.
Wright, Donald

Union County

Allen, David Eugene
Anaya, Carlos

Anreder, Michael Barry
Anzalone, Gary
Barenberg, Andrew
Bevill, Gary L.

Booker, J. Gregory
Bryant, D’Orsay III
Carroll, Peter J.
Cyphers, Charles D.
Daniels, C. Dwayne
Davis, Richard K.

Deere, Joy #

Dietzen, Richard E.
Dixon, R. Mark
Dudick, Stephen
Duzan, Kenneth R.
Edmondson, C. Douglas
Elliott, Wayne G.

Ellis, Jacob P.
Fonticiella, Aldo V.
Forward, Robert B.
Fraser, David B.

Gati, Kenneth G.
Germann, Robert E.
Giller, W. John Jr.
Gomez, Henry L.

Hill, Grady Jr.

Holleran, John R.
Hopson, Deanna
Jenkins, Chester W.
Jones, Steve A.

Jucas, Diana T.

Jucas, John J.

Kang, Gurprem Singh
King, Billy D.

Kinslow, Ivory
Landers, Gardner H.
Massanelli, Gregg L.
Menendez, Moises A.
Mohan, Kumaran K.
Murfee, Robert M.

Ong, Tie S.

Pillsbury, Richard C.
Pirnique, Allan S.

Posey, Willie II
Ratcliff, John
Rogers, Henry B.
Sample, Dorothy C.
Sarnicki, Joseph
Schonefeld, Michael D.
Schultz, Wayne H.
Scurlock, William R.
Seale, James E. Jr.

Shah, Asim Ahmed
Smith, George W.
Stevens, Willis M. Jr.
Talley, H. Aubry
Tolosa, Elizabeth
Tommey, C. E.

Tommey, Robert C.
Turnbow, R. L.

Ulmer, Minna I.
Vogenitz, William

218® The Journal

Volume 97

2000 Arkansas Medical Society Membership Roster

Union ■ White County

Warren, George W.
Watson, Donya
Watson, Robert A.
Weedman, James B.
Williamson, John R.
Wilson, Larkin M. Jr.
Yocum, David M. Jr.
Zahniser, Donna J.

Van Buren County

Belizario, Marcelino C.
Hall, John A.

Pearce, Charles G.
Pineau, Greg
Starnes, Harry

Washington County

Albright, Spencer III
Allen, B. Eual
Applegate, C. Stanley Jr.
Arnold, James A.
Atwood, H. Daniel
Bailey, Donald C.

Bailey, Scott
Baker, C. Murl Jr.

Baker, Donald B.

Beck, J. Thaddeus
Beck, William A.
Beckman, James Jr.
Billingsley, John A. Ill
Blankenship, James B.
Bonner, Mark
Box, Ivan H.

Boyce, John M.

Brooks, D. Wayne
Brooks, W. Ely
Brown, Craig
Brown, David L.

Brunner, John A. Ill
Burnside, Wade W. Jr.
Burton, Anthony R.
Butler, G. Harrison
Carver, Joel D.

Chase, Patrick R.

Cherry, James F.
Churchill, David
Clouatre, Michael Paul
Coker, Tom Patrick
Cole, George R. Jr.
Cooper, Craig
Councille, Clifford C. Jr.
Crittenden, David R.
Crocker, Thermon R.
Cross, Michael J.
Cunningham, Darrin D.
Danks, Kelly R.

Davis, David A.

Davis, Randall
Decker, Harold
Deen, Lewis S.

Dodson, C. Dwight
Duke, David D.

Duncan, Philip E.
Dykman, Thomas R.
Eck, Gareth
Embry, Travis D.
Endsley, Charolette
Ferguson, Susan Portis
Fincher, G. Glen
Fink, Roger Lee II
Fish, Ted J.

Fossey, Carol
Gardner, Buford M. #
Garibaldi, Byron T.
Garner, Hershel H.
Ginger, John D.

Gray, Dalton L. II
Grear, Danna
Green, Michael D.
Grote, Walton
Gyles, Nicholas R. II
Haisten, James
Hall, Ben
Hall, Joe B.

Hamilton, Herbert E.
Harris, David Jay
Harris, Murray
Harris, Paul L.

Harris, W. Duke
Harrison, William F.
Hart, Hamilton R.
Hayward, Malcolm L. Jr.
Hedberg, Curtis
Heinzelmann, Peter R.
Hendrycy, Paul R.
Henry, Morriss M.
Henry, Paul M.
Higginbotham, Hugh B.
Higginbothom, William
Hollomon, Michael
Hui, Anthony
Hurlbut, Kevin
Hutson, Martha
Hutson, Sanford E. Ill
Inlow, Charles W.
Jaderborg, Jana M.

Jay, Gilbert D. Ill
Johnson, Brad D.
Johnson, Miles M.

Knox, D. Luke
Koehn, Laura J.
Kraichoke, Saran
Kyle, Richard
Lloyd, Richard A.

Loftin, Teresa D.
Magness, C. R.

Martin, F. Allan
Martin, William C.
Mashburn, James D.
McAlister, Joseph H.
McAlister, Mitchell
Me Bee, Sara
McDonald, James E. II
McElroy, Kellye

McEvoy, Francis
McGhee, Linda M.
McGowan, William
McNair, William R.
Miller, Charles H.
Miller, Mark E.

Mills, William C. Ill
Mitchell, Banford R. Jr.
Moon, Steven L.
Moore, James F.

Moose, John I.

Morse, Michael
Mullis, R. Jay
Murry, J. Warren
Nettleship, Mae B.
Nowlin, William B.
Ortego, Terryl J.

Pang, Robert R.
Parashara, Deepak K.
Park, John P.

Parker, Lee B. Jr.
Patrick, James K.
Pearson, Fran
Pichoff, Bruce Edward
Pickett, James D.
Pickhardt, Mark G.
Pope, Kevin L.

Powell, Mark W.

Power, John R.

Proffitt, Danny L.
Raben, C. A. Tony
Riddick, Earl B. Jr.
Riner, Dan M.
Rogerson, Susan H.
Romine, James C.
Rosenzweig, Kenneth
Ross, Joseph
Rouse, Joe P.

Runnels, Vincent B.
Saitta, Michael R.
Salvador, Ester Arejola
Sandefur, Barbara A.
Sanders, Scott
Sandler, Richard
Schemel, Lawrence J.
Schmidt, Clinton C.
Sexton, Giles A.
Sexton, Jon A.

Shaddox, T. Stephen
Sharkey, Martha Ann
Sharp, Jim D.

Siegel, Lawrence H. #
Simmons, Thomas
Simpson, Todd R.
Singleton, E. Mitchell
Sisco, Charles P.

Smith, Austin C.
Snyder, Norman I.
St.Clair, Kevin
Stagg, Stephen W.
Taylor, Robert G.

Tellez, Guillermo J.

Thomas, Gary A.
Thomas, Joanna M.
Thorn, Garland M. Jr.
Titus, Janet L.

Tuttle, Larry D.
Ureckis, David
Weed, Wendell W.
Weiss, John B.

Wheat, Ed Jr.
Whiteley, Andre
Whiting, Tom D.
Williams, John R.
Wood, Jack A.

Wood, Russell Hunter
Wood, Stephen T.

White County

Asmar, Salomon
Baker, Ronald L.
Ballinger, Phillip Scott
Bell, John
Blakely, Brent M.
Blickenstaff, Kyle R.
Blue, Glen T.

Blue, Leon R.

Brown, Arnold R.
Brown, Mark A.
Brown, Peggy J.

Brown, Terry Mac
Bums, Jerry
Citty, Jim C.

Collier, Steven F.
Covey, David C.
Davidson, Daniel
Dicus, G. Scott
Dugger, Joseph S.
Elliott, Robert E.
Fincher, S. Clark
Formby, Thomas A.
Gardner, Jack R.

Gibbs, William M. Ill
Golleher, James H.
Hannah, J. Todd
Hatfield, David L.
Henderson, John C.
Holston, John S.
Jackson, Clarence W.
Johnson, David M.
Joseph, Eugene A.
Justus, Michael G.
Killough, Larry R.
Kinley, J. Garrett
Koch, Clarence W. Jr.
Lefler, Stephen F.
Lewing, Hugh S.

Lewis, James Sheridan
Lowery, Benjamin R.
Lowery, Robert D.
McAdams, Edward L.
McCoy, James R.
Meacham, Kenneth R.
Moore, Donald

Number 6

December 2000 • 219

White County - Direct Members

Arkansas Medical Society 2000 Membership Roster

Moore, Jesse
Muirhead, Michael J.

Nevins, William H.

Norris, E. Lloyd
Payne, Cheryl
Ramirez, Raul
Ransom, C. E. Jr.

Riddick, Robert S.

Risinger, Melanie W.
Robertson, William T.
Rodgers, Porter R. Jr.
Sanchez-Montserrat, Rafael
Schwartz, Stanley S.

Shultz, Sam L.

Simpson, James A.

Smith, Bernard C.

Smith, Bob W.

Spence, Don K.

Staggs, David L.

Stinnett, J. L.

Tate, Sidney W.

Thompson, Bruce
Weathers, Larry W.

White, Bradley
White, William M.

Williams, W. Curtis
Yates, Terrence
Young, Jack S. Ill

Woodruff County

Hendrixson, Basil E.

Rowe, James E.

Yell County

Banning, Michelle Shelly
Green, Terry G.

Hodges, Jerry F.

Isely, William A. Jr.

Martin, Damon G. H.
Maupin, James L.
Pennington, James O.

Ring, Gene D.

Russell, Gary W.

Scott, William P.

Tippin, Philip

Direct Member

Abdulrauf, Saleem I.
Aboul-Magd, Ahmed S.
Akkad, Nabil
Albin, Amy Wilson
Alexiou, Jerri
Alfano, Thomas G.

Allard, Mark
Anderson, Patric Neil
Anderson, Roger Wilbert
Andreoli, Thomas E.
Andrews, Nancy R.
Angtuaco, Sylvia S.O.
Antakli, Tamim
Araneda, Erick R.
Athurguthu, Jithendra Mohan

Bacon, Lori
Baker, Karen
Banaji, Sudesh
Barone, Gary
Barrett, Rebecca
Baxley, Paul J.

Beebe, William E.

Beeman, David
Benafield, Robert B.
Bingham, Jennifer A.
Blackstock, Terri
Blaszak, Richard T.

Bonwich, Janina B.

Bowman, Raymond N.
Brodsky, Michael
Brooks, Homer E. Ill
Brown, Richard E. Jr.

Brown, Robert D.

Brull, Sorin J.

Bums, Stanley
Bushman, Gerald A.

Camp, Michael
Campbell, James A. Jr.
Cannon, R. David
Cardenas, Jaime A.

Carey, Martin John
Carey, Victor Jr.

Carroll, Barry
Carter, Inge Renate
Cash, J. Steven
Cashion, Ernest Lowery
Cerrato, Deborah
Chan, Kenneth
Chandler, Rodney
Cheek, William Clark #
Cheney, Lori M.

Chitwood, G. Glen
Chu, Tommy D.

Clark, Teresa
Claycomb, Scott C.
Cohagan, Donald L.

Coke, Courtney C.

Coker, Tom P.

Collins, John O.

Cook, Joseph A.

Counce, James S.

Cox, Judd G.

Daidone, Paul E.

Day, David W.

De Miranda, Federico Carlos
DeSoto, David J.

Dinehart, Scott
Dmowski, Andrzej T.

Dolak, James A.

Duke, J. Richard
Dunigan, Rodger
Dunn, Laura

Eaton-Wilmoth, Rayettea L.
Ebel, Susan
Economides, Nicholas
Edattukaren, Varghese
Edwards, Peter M.

Ekanem, Felix
Ellis, Margaret P.

Emery, Robert
Farajallah, Awny
Farst, Karen J.

Feiz, Vahid
Ferrer, Thomas J.

Fiser, Debra H.

Flanigin, Richard
Florendo, Noel
Freeman, Jerre M.
Freeman, William H.
Frigon, Gary F.

Gardial, J. Richard
Gensler, Thomas D.
Gilbert, Jimmy
Gober, Gregg
Goodman, Jack
Goodson, Timothy C.
Gordon, Alfred Y. Jr.
Gordon, Gayle
Graham, Charles J.
Greene, Graham F.
Gregory, Jo Anne
Griffin, Frankie M.
Grisham, Dannetta
Gungor, Anil
Guyer, Janet
Haas, David C.

Haran, Panchapakesan P.
Hardin, A. Scott
Hardy, Kyle G.

Harik, Sami I.

Harper, Richard
Harrell, Robert E. Jr.
Harris, Russell
Harris, Shirley D.

Hass, Farrell D.

Heard, Jeanne K.
Henry-Tillman, Ronda S.
Hester, Wes
Hilman, Michael G.
Himmelstein, Stevan I.
Hodges, John M.
Holloway, David H. Jr.
Hudson, Amy R.

Hughes, Alan W.

Hughes, Laurie O.
Hurwitz, Mervyn B.
Huynh, Chanh V.
Ibrahim, Hossam
Imamura, Bryan
Istanbouli, Wajih
Izard, Ralph S. Jr.
Jabbour, J. T.

Jackson, Charles A.

Jasin, Hugo
Jewell, Shannon
Jimenez, Jorge F.

Johnson, Sandra
Johnston, Greg
Jones, Robert E.

Joseph, Jacob
Kale, Robert
Kazakevicius, Rimantas
Kempson, Steven E.
Kendrick, Carl M.

Khan, Ahmed
King, William R.

Kinney, Joyce
Kirchner, Jeffrey
Kirchner, Jo Ann
Kiss, Csaba
Kluck, Carl Jr.

Knowles, Glen C.

Koenig, A. Samuel III
Kremp, Richard E.

Krisht, Ali F.

Laffoon, Gregory
Lamps, Christopher A.
Lane, Joel Robin
Lang, Patricia A.

Lawrence, Debra C.
Lazenby, John
LeBoeuf, Dorothy
Lewellen, Thomas Lynn Sr.
Lewis, Charles
Linskey, Mark Elwood
Lipsmeyer, Eleanor
Lister, Danny
Little, J. Aaron
Lorenzo, Edilberto B.
Lowery, Lisa
Lyle, Robert
Lynch, Paula
Mallare, Johanna
Marotti, Tonya L.

Marshall, Glenn E.
Maxwell, Teresa
Mayhew, Kathy
McAndrew, Brian P.
McKenzie, James
McMicheal, Wanda V.
Meador, A. Sharon
Miller, Laurence H.
Moffett, Shirolyn R.

Moin, Khurram
Moutos, Dean M.

Murry, William L.

Nader, Nader D.

Nadvi, Samina Zareen
Nelson, Richard A.
Newcomb, T.L.

Newton, J. Camp
Nichols, Scott
Osofisan, Olaniyi
Paine, Johnny R.

Pait, Thomas Glenn
Papageorge, Dean
Pappas, Lila
Pappas, Paul H.

Parchman, A. Janette
Parker, A. Wade
Partridge, Paige M.

220 • The Journal

Volume 97

2000 Arkansas Medical Society Membership Roster

Direct Members - Students

Paulson, Kathleen
Perkins, Lalita
Phillips, David Lance
Phomakay, Von
Ploetz, Carina
Plunk, Hermie G.
Porterfield, James G.
Powers, Robert
Prince, Audra M.

Purnell, Gary L.

Rasberry, Ronnie D.

Reddy, Krishna
Reid, Graham M.
Robertson, John A.
Robinson, Martin J.
Robinson, Nancy
Rodgers, Kenneth
Rodkin, Richard S.
Rodriguez, Johnny R.
Rodriguez, Linda M.

Rowe, Tracy L.

Rucker, Gari
Rumans, Todd M.

Sakr, Safwan
Samman, Zaki A.

Saucedo, Jorge F.
Schexnayder, Stephen M.
Schmidt, David
Seib, Paul M.

Shah, Rajesh V.

Shapira, Iuliana T.

Shaver, Robert
Sheikha, Mouhammed K.
Sherman, Alan W.

Short, Luke H.

Sites, Terry Jay
Slezak, James
Smith, Carl
Smith, Eugene III
Smith, Kirby L.

Snow, Sandra L.

Speed, Darrell
Standefer, J. Michael
Starnes, C. Wayne
Steely, Donald
Stern, Thomas N.

Stewart, David L.

Stumer, William Q.
Sullivan, Sarah L.

Sweeney, Lynn
Tait, Amy
Tait, Layne
Talley, J. David
Tanner, Paul R.

Teal, Linda
Thomas, Jonathan
Thompson, Jerome W.
Thompson, Robert C.
Thomsen Hall, Kathleen #
Tollett, Michael Hines
Tutt, Richard D.

Tutton, James

Van Hemert, Rudy
Veach, Paul A.
Vermont, Charles
Waheed, Atiya N.
Waldron, James A. Jr.
Walker, Brent
Waller, John
Ward, Joseph P.
Warmack, Asa M.
Webb, John W.
Westwood, John Jr.
Wharton, James R.
Wheeler, Richard
White, Faber A. Jr.
Williams, Chrysti
Williams, Debra
Williams, Nancy K.
Williams, Sonia T.
Willis, Charlotte
Wilson, Matthew
Wilson, Robert B. Jr.
Wilson, Steven K.
Wood, Michael D.
Wren, Mark
Yawn, Timothy
Yetman, Anji T.
Yoltar, Rukiye
Young, Jeffrey P.
Young, Michael C.
Young, Sandra S.
Yuen, James C.

Yunus, Nauman
Zelk, Misty M.

Zini, James E.

Students

Abdin, Jamal
Acott, Alison A.
Afsordeh, Nirvana
Ahrens, Mitchell A.
Akbar, Safdar Ali
Akins, John P.
Alexander, Jan
Ancalmo, Claudia M.
Arthur, David E.
Ashbrooks, Darrin D.
Athota, Anupama B.
Baggett, Stephanie
Bailey, Amy E.

Baker, Ashley
Baker, Robbie C.
Baker, Todd F.

Baltz, Alexander J.
Barden, Michael G.
Bariola, Jeremy R.
Barker, Lisa R.

Barr, Susan
Beard, Jessica L.

Beck, David
Beck, Jason D.

Bell, Tanya R.

Bell, Todd E.

Bess, Barbara
Bhattacharyya, Debasish
Bibb, Brad
Bibbs, David L.
Bierbaum, Anna C.
Bierbaum, Walter F.
Bishop, Michelle
Blanchard, Mary
Bledsoe, Samuel E.
Bohra, Robin I.

Boling, Carrie T.

Booth, Billynda L.

Borg, Clayton D.
Bowman, Vernon D.
Bracy, Brian
Bradshaw, Mark
Brannick, James M.
Brashears, Reta
Braswell, Leah E.
Brewer, Jim E.

Brown, David P.

Brown, Donna
Brown, Scott P.

Bryant, Gwendolyn M.
Bryant, Shelly L.
Bufford, Jeremy D.
Burris, Cara B.
Campbell, Jenny
Campbell, Lucas K.
Campbell, Rachel C.
Carlton, Caroline F.
Carozza, Michael C.
Carrouth, David
Carter, Sherri R.

Casey, Sean P.

Cash, Jodi L.

Cassat, James E.
Causbie, Jessica
Cawich, Ian
Cawyer, John C.
Chalfant, Paul
Chi, Jasen C.

Chism, Brandon
Citty, James K.

Clingan, Warren
Cobb, William C.
Cogbill, James M. Jr.
Coleman, Brendan
Collins, Sidney W. Jr.
Cook, Michael
Cordell, Cari L.
Cordon, Krista J.
Counts, Brian W.
Covert, Kent
Cox, Wesley
Craig, Jennifer
Crider, Stacy L.

Criner, Owen K.
Croker, Mary Ellen
Cupples, Laura E.
DaVeiga, Adriana
Daily, Jason G.

Daniel, Andrew D.
Dannaway, Douglas C.
Dannull, Kimberly A.
Dare, Jason A.

Darwin, Amy L.
Daugherty, Jeremy
Davidson, April
Davidson, Gretchen M.
Davis, James O.

Davis, Jeremy C.
DeWitt, Keitha R.
Denton, Meredith
Depko, Joshua M.
Dickinson, Jacob
Diemer, Heather M.
Dill, Kenneth
Dolbeare, Dirk W.
Dopkou, Joshua
Dorman, Robert B.
Dougan, Jason O.
Downen, Brian
Drobena, Gina A.

Duffy, Laura
Dunlap, Melinda S.
Dunn, Jeremy
Dwyer, R. Gregg
Dye, Daniel
Dyer, Mark A.

Earl, K. Sam
Easley, Seth
Eharb, Jeanette M.
Ekechukwu, Martina C.
Ellis, Michael
Engle, David B.

Ennis, Jared S.

Enns, Michael W.
Evans, Clinton E.
Evans, Melia
Faddis, Lance A.

Fagen, Bryan C.

Fallon, Amy M.

Fisher, Andrew M.
Fitzgerald, Ryan T.
Fletcher, Brent F.
Fletcher, Terry
Flowers, Rebekah
Fong, Shirley
Fore, Daniel B.

Forrest, Robert P.

Fox, Patrick J.

Fraley, Patrick L.
France, Erica H.
Frederick, John T.
Freeland, Michael B.
Frego, Jonathan L.
Gathright, Kenneth
George, Matthew S.
Geren, Blake
Glasgow, Meriden A.
Glass, Melanie D.
Glover, Forrest D.

Go, Jean K.

Number 6

December 2000 • 221

Students

Arkansas Medical Society 2000 Membership Roster

Golden, Carmen N.
Goodman, Brian
Goodwin, Whitney J.
Goosby, Nova D.

Gordin, Audrey L.

Gordon, Eric H.

Graham, Charles G.
Graham, Jeffrey B.

Gray, Rickey C.

Green, Edward D.

Gupta, Ramona
Gustafson, Craig A.

Hair, Kelly C.

Hall, Annette N.

Halter, Steven J.

Haltom, John
Hardin, Laura A.

Harjan, Harjot S.

Harris, Bryson C.
Harrison-Lightbum, Marla K.
Haustein, Matthews
Hawkins, William L.

Hayes, William J.

Haynes, Katherine L.
Heinzelmann, Andrew D.
Hellmer, Thomas R.
Hendren, Ryan L.
Hendrickson, Blair L.
Henriksen, John
Henry, Lance B.

Herrin, Kathy J.

Hinton, Jeremy
Hinton, Richard W.

Hoang, Thuy T.

Hodges, Anissa
Hogan, W. McCall Jr.
Holden, James R.

Holder, Kasey M.

Holt, Jason L.

Hooper, Matthew C.
Hopkins, Sarah E.

Howard, Don N.

Hughes, Angela
Hughes, Bradley R.

Hunt, James
Hunt, Justin
Huntley, Andrea L.

Hurt, Jason W.

Hussain, Elora
Hussain, Tanvir
Hutton, Theron
Hyatt, Bryan T.

Ison, Keith A.

Jackman, Kimberly M.
Jacobs, Kelly A.

Jansen, Joe
Jansen, Stephen
Janson, Brian J.

Jarrard, Kristin A.

Jauss, Kewen
Jensen, Beth A.

Johnson, David G.

Johnson, Dwight J.
Johnson, Jeff W.

Johnson, Kelly C.

Jones, Bridgette L.

Jones, David G.

Jones, Sherri
Jones, Steven S.

Jones, William S.

Jordan, Barry
Joshua, Jabbar A.

Jumper, Zachary
Kaakaji, Rami
Kaufman, Melissa R.
Keels, Tansyla D.

Kelley, Morris
Kelly, Derek
Kemp, Susan A.

Kendall, William B.
Khan, Adnan
Khan, Amir S.

Kim, Charles
Kim, Peter J.

Kincade, Matthew
King, Kristy S.

Kirby, Deborah
Kit, Brian K.

Kleinbeck, Seth M.
Klutts, James
Knott, Kyle
Koffler, Molly
Krenn, Louis P.

Kueter, Daniel B.
Kuykendall, Tracy
LaGuardia, Stephen
LaRue, OaKley
Lai, Michelle
Lam, David
Lamkin, Anthony W.
Lavender, Kristopher
Lawrence, Kevin
Lawson, Nicole M.

Le, Vu

Leach, Pamela
Lebeda, Ray
Lee, Jonathan
Leslie, John T.

Lester, Robert
Lewis, Johnathan W.
Lewis, Steven R.

Lindsey, Marla E.

Linn, Brian K.

Linsky, Russell A.

Lipke, Lindsay A.
Lipsmeyer, Christopher P.
Loe, Shanan M.

Lofton, Jason D.
Lombeida, Heather
Lombeida, Juan
Lou, Angela
Love, Monica
Lovelace, Kimberley
Luistro, Anthony

Lyle, C. Wayne
Madden, Mac Jr.

Maner, Jamie
Manning, Thomas A. Ill
Manry, James A.

Markey, Janell M.
Martin, Cade
Mashek, Charles C.
Mason, William
McAnulty, Brent C.
McBain, Stacy
McCallum, Sanford B.
McCarley, James R.
McCarty, Christopher
McCarver, Rodney H.
McCauie, Theresa
McCoy, Justin L.
McParlane, Adrienne C.
McGarity, Timothy
McGaugh, Janette
McGeorge, Susan M.
McGowen, Philip H.
McGrimley, Laura M.
McKelvey, Samantha S.
McMasters, Mark A.
McNew, Gina L.

McVay, Marcene R.
Meads, Anthony
Menendez, Chris A.
Merryman, Daron E.
Middleton, Jennifer L.
Middleton, Owen L.
Milam, Sarah
Miles, Caroline S.
Molden, Raymond K.
Montgomery, Matthew
Mooberry, Micah J.
Mooney, Brian W.
Moore, Amy
Moore, Arthura D.
Moore, John D.

Moore, Pittman D.
Moran, Scott
Morgan, Derek L.
Morgan, James
Moseley, Tommy H.
Moss, Allison
Moss, Mark
Mull, Kawonia
Murphy, Brandon D.
Nazaruk, Rachel Ann
Nelson, Joseph P.
Nelson, Tyler
Nicholas, Kremer B.

Nix, Matthew
Nunez, Rebekah
O’Bryan, Gerald K.
O’Neal, Heather
Oge’, Brian T.

Osborn, Matthew B.
Owen, Anthony
Owen, Justin L.

Owen, Marcus A.

Owens, Daniel J.

Padilla, Kricia D.

Pafford, Michael B.

Pai, Vinaya B.

Paladino, Johnathan D.
Palmer, Jonathon D.
Palmer, Kricia P
Palmer, Lolita V.

Palmer, William J.
Palmer, William S.
Panek, Ralph C.

Pardue, Michelle L.

Park, Jong C.

Park, Jong S.

Parker, Jonathan M.
Parnell, Amy Carol
Patel, Nimesh
Patterson, Deric W.

Paul, Eric M.

Payne, Michael D.
Peldun, Renee G.
Pennington, Jaymie H.
Perick, Ted M.

Perrin, Shelly
Pesek, Robbie D.

Phan, Dan C.

Phelps, Dawn
Phillips, Amanda R.
Pierce, Barry D.

Pillow, Gill G.

Pittman, Christopher
Pittman, Shannon
Pleasants, Elizabeth
Polkowski, Gregory G. II
Poon, Kenneth Y.

Pope, Mark
Porchia, Sylvia
Powers, Cara
Price, Joanne
Pritchard, Charles
Provost, Scott L.
Qualls-Statler, Kristi L.
Qureshi, Irfan
Rabjohn, Pat A.
Ragland, James
Rankin, Joshua D.
Ransom, Michelle M.
Raper, Thomas B.

Rapp, Jennifer A.
Rashweed, Kashaf
Reeves, Charles Jr.
Reynolds, James J.
Richmond, David A.
Rippy, Kelli L.

Robert, Stephen M.
Roberts, Gregory J.
Robertson, Sarah E.
Robinson, Eric
Ross, Jonathan H.
Royster, Eric
Russell, James L.

222 • The Journal

Volume 97

2000 Arkansas Medical Society Membership Roster

Students - Residents

Russell, Sheri L.

Rutledge, Estelle A.

Sanders, Jarret D.

Sanford, Garrett
Sarver, Matthew R.

Schlegel, Kelly
Schluferman, Christopher A.
Schmucker, Tracey A.
Schneider, Elizabeth A.
Schriver, Byron L.

Scifres, Whitney J.

Scrape, Scott R.

Seale, Jared J.

Seibert, John W.

Self, Matthew
Sellers, Matthew A.

Seme, Melissa D.

Seribner, John
Shah, Neilesh Kumar
Shanlever, Suzanne J.
Shannon, Melissa L.

Shelton, Jeffrey W.

Shipman, Grover
Showalter, Heath
Shrum, Steven M.

Shultz, Erik R
Sills, Adam A.

Silvey, Brentley
Sloan, Anthony B.

Sloan, Valerie A.

Smith, Jason
Smith, Jevin A.

Smith, Marcus
Smith, Philip
Spann, David C.

Sparks, Matthew A.

Spencer, Clay R.

Stacey, David H.

Staggs, Brent C.

Stallcup, Jim W.

Starnes, Harrison B.

Statler, Kristi Q.

Steed, Matthew G.

Stennett, Melissa D.
Stephens, Greg
Stevens, Charles
Stewart, Brent T.

Stewart, Eric J.

Stewart, Garry
Stewart, Tami W.

Storm, Elizabeth A.

Strnad, Petra
Stroud, Michael H.

Sublett, Jack D. II
Surati, Millie J.

Svoboda, Robert P.

Swift, Shannon S.

Swymn, Jeremy
Ta, Huong J.

Talbert, Lisa
Tarini, Gregg L.

Tate, Wesley A.

Taylor, John
Tharp, Shane
Theilken, Luke S.

Theus, John W.

Thies, Joseph B.

Thomas, Brad A.

Thomas, Martha
Thompson, Bobby
Thompson, John W.
Thompson, P. Keith
Thomsen, Isaac P.

Tilley, Spencer B.

Totten, Matthew B.

Treece, Brannon
Turney, Nathan W.

Tyler, David E.
Tyler-Hashemi, Alexander A.
Unger, Adriana M.

Vancil, Tobias J.

Vanderburg, Edward
Vester, Sara E.

Vickery, Jason E.

Vogler, Carolyn E.

Vyas, Keyur S.

Wagner, Michael D.

Wagner, Tommy W.

Walker, Christy W.

Walker, Torrance A.
Wallace, Aaron
Wallace, Bradley A.

Walsh, Donald
Wang'Gillam, Andrea
Ward, Aaron R.

Ward, Leslie D.

Warford, Jeremy A.
Warriner, Amy H.

Wassell, David L.

Wayne, Brian
Webb, Christopher
Webb, Jonna
Wells, Robert
Welter, Kimberly R.

Wenger, Alyssa N.
Weyenberg, Matt G.

Whaley, Kevin D.

White, Faber A.

White, Jonathan D.

White, Justin S.

White, Michael
Whitlock, Shane
Wilbert'Starks, Tasha
Williams, Melissa B.
Williams, Misty Leigh
Williams, Rhonda J.
Williams, Sharenda L.

Willis, Sherita D.

Winkley, Rachel
Wirges, Richard S.

Wise, Jeremy
Wise, Marc E.

Witherington, Brent V.
Wood, Melissa

Woodruff, Anthony J.
Woods, B. Gennice
Wooley, Katherine D.
Wright, Lonnie B.

Wu, Michael C.

Wyrick, Theresa
Yarnell, Bryan
Yawn, Melissa M.

Young, ErikJ.

Zawada, Gregory
Zwiesler, Daniel J.

Residents

Adams, Laura L.

Adler, Ira
Aguinaga, Miguel
Ahart, Cheryl L.

Ahmad, Ibrahim
Aidoo-Akama-Makia,
Jennifer A. #

ALNashif, Ali
ALTakrouri, Hatem A.
Alam, Muhammad G.
Albanna, Ahmed Q.S.
Albertson, Christopher M.
Alberty, Bernadette A.
Alexiou, Michael A.

Allen, Julia
Anthony, Angela
Appelgren, Rebecca
Arendall, Clarence J.
Arick, Carmen L.
Arnautovic, Kenan I.
Arnold, James R.

Arora, Harendra
Arthur, Lee E.

Atreides, Sean-Paul
Bacchus, Amy C.

Bailey, W. Brian
Bakhtawar, I ram
Ball, Peter H.

Ballard, Devon R.

Baltz, Tracy C.

Barboza, Jodi M.

Barkai, Alex
Baselious, Joseph
Bayer-Garner, Ilene Bertha
Belk, James
Be lk, Robert J.

Belue, Kara D.

Bennett, Leigh A.

Benton, Thomas H.
Berestnev, Konstantin V.
Bertrand, Skipper J.

Bhutta, Adnan T.

Bhutta, Sadaf
Blair, Brian H.

Bland, Marnie
Blankers, Christian G.
Bledsoe, Gregory
Boger, Eve H.

Boger, William G.

Boone, Ryan
Borisova, Irina
Braswell, Camille S.
Brock, Wade D.

Brown, Columbus
Brown, Daniel K.

Brown, Keith
Brownfield, Shannon H.
Bryant, Christopher S.
Buffalo, Ryan P.

Bullard, Michelle
Burke, Richard A.

Burks, Jennifer E.

Butler, Kathleen V.
Cadle, Kimberly
Cannon, Thomas C.
Carlton, Randall
Cash, David
Cash, Paige P
Cathey, James D.
Cavaneau, Nick
Ceola, Ashley
Ceola, Wade
Chadha, Mandeep S.
Chatoth, Dinesh K.
Chavis, Brent D.
Cheema, Puneet
Chen, Jing X.

Chen, Xiaoling
Chiles, Melissa
Chiles, Walter III
Chumley, Willard T. Jr.
Clardy, Bryan H.

Cobb, J. Christopher
Cockrum, Holly D.
Cody, Stephanie G.
Cogbill, Kay L.

Coker, Raymond K.
Cole, Richard W.
Collier, Jack
Collier, Susannah
Collins, Gwynetta M.
Collins, Vera Y.

Cooper, Kara
Coppola, Angelo Jr.
Corbell, Mark E.

Cotner, James B.
Cowherd, Kristy
Cowherd, Robert M.
Crisp, Constance J.
Daniel, Jamie
Danner, Christopher
Dansby, Jason
Davis, John C.

Davis, Jonathan
Davis, Richard K. Jr.
Dawson, Justin D.

Day, Jeffrey L.
de Saint'Felix, Douglas
DeNeen, Andrea’ E.
Denson, Alyson
Devarajan, Sumathi

Number 6

December 2000 • 223

Residents

Arkansas Medical Society 2000 Membership Roster

Dickson, Brian G.

Dickson, Scott M.

Diles, Timothy R.

Dillaha, Jennifer
Dominguez-Ventura, Alberto
Dvoryansky, Andrew
Eads, Lou Ann
Easom, Delilah L.

Eble, Brian
Eckles, Laura W.

Elliott, Jana
Elnabtity, Mohamed
England, Lane G.

Ensminger, Bobby T.

Escarda, Joe O.

Fahr, Michael
Faith, Jennifer J.

Fant, Jerri S.

Farmer, Kimberly J.

Feng, Zuliang
Ferguson, Philip E.

Ferguson, Scott
Ferrill, Shelley C.

Flaxman, Neesa Jill
Fogata, Maria Luisa C.

Foley, Regina P.

Fort, David Jr.

Foster, Jason
Fox, Clinton W.

Franks, Jason A.
Freyaldenhoven, Timothy E.
Frino, John
Furlow, John L.

Furlow, Stacy H.

Garcia, Robert
Gardner, Edward
Garlapati, Butchaiah
Garrett'Shaver, Martha G.
Garrison, Robert L. II
Gaston, Caleb O.

Ghafoor, Abid
Gibbons, Glenn G.

Gibson, Danielle C.

Gibson, William D.

Goeke, Brad J.

Grammer, W. Cody
Graves, Blane A.

Gray, Adam C.

Gray, David J.

Gray, Heather C.
Greenwood, David
Gregory, J. Minor
Griffin, Gary E.

Guinn, Robby C.

Guinn, Spencer H.

Gungor, Neslihan
Gupta, Navneet
Gwamicki, Danuta
Habibipour, Saied
Hadi, Ehsan M.

Handloser, Holly H.

Hannon, Martin A.

Harik, Nada
Harlan, Brian
Harms, Sally S.

Harris, Daniel
Harris, Julie A.

Hart, Michael
Hartman, Arthur R.

Harton, Scott
Harvey, Shelly M.

Hays, Deborah A.

Heif, Muhannad M.

Helsel, Jay C.

Herring, John
Higgins, Rhonda Edison
Hillis, Thomas M.

Holland, Cheryl
Hollis, Thomas H. Jr.
Holmes, David G.

Holmes, RonaBeth R.

Holt, Brent E.

Hoover, Melanie D.

Horan, Chris
Hoskins, Gregory C.
Houston, Melinda L.
Hudson, Stephen A.
Hutcheson, James
Irish, Katherine A.

Jackson, Kevin T.

Jackson, Matthew P.

Jackson, Phillip C.

Jacobs, Robert
James, William M.

Jarvis, Robert M.

Jayaprabhu, Sudheer M.
Jetton, Christina A.

Johnson, Brad R.

Johnson, Jennifer
Johnson, Larry “Jack” Jr.
Johnson, Michael W.
Johnston, Alan C.

Jones, Chrystal D.

Jones, Karla R.

Kajitani, Michio
Karim, Aftab
Kazzar, Nelly Y.

Kellar, Jeffrey
Kellow, Amir L.

Kelly, Owen L.

Kern, Gordon

Khassawneh, Basheer Yousuf
Kidd, Joseph Jr.

Kinchen, Delaney L.

Kinsey, Toyya
Kligman, Svetlana
Knox, Christopher G.
Koehler, Kevin R.

Kolb, David
Konis, George
Kota, Manjusha
Ku, Tsun Sheng
Kubacak, Brian M.

Kueter, Joseph C.

Kumar, Priya
Kyasa, Mouhammed
Kyser, Steven M.

Lassieur, Susanne M.
Latch, Rebecca L.

Layton, Ann D.
Leatherman, Bryan D.
LeDay, Romona
Lee, Ronnie D.

Lehmkuhl, Rachel J.
Lewis, Barrett D.

Lian, Fangru
Lightfoot, Meredith L.
Lochala, Roddy
Long, Eric D.

Long, Michael J.

Lu, Ellen
Luelf, Claire J.

Luper, Rebecca
Lynn, W. Steve
Maddock, Thomas J.
Magre, Ann-Marie
Mahdavy, Mustafa
Major, Victoria E.

Malik, Vipin
Manarang, Don V.
Manavalan, Pius Louis
Mangat, Halinder
Markham, Larry
Martin, Dawn
Martin, Kristi
Massoll, Nicole A.
Mathew, Sajini
Mayfield, Jan
McCall, Tyrone L.
McClain, Charles M. Ill
McCourtney, Bill R. II
McDonald, Rodney K.
McDonnell, Bryan Dale
McDonnell, William M.
McGraw, Lisa K.

McKee, John D.
McKinney, Vanessa L.
McNellis, Emily M.
McNellis, Ryan E.
McNiece, Karen L.
Meakin, Kevin David
Merman, Rita
Merrick, Jason A.

Moak, Candace
Moix, Frank M. Jr.
Molina, Diane K.
Montgomery, Christopher
Moore, Heidi L.

Moore, Troy G.

Morgan, Christopher O.
Morgan, Justin E.

Morgan, Kelly J.

Moss, Mark E.

Munir, Kavanaugh
Munir, Muhammad T.
Myers, Janette E.

Myers, Michael
Nelson, Elizabeth B.
Nelson, James C. Jr.
Netherland, Clinton
Nguyen, Larry
Nguyen, Xuan-Mai T.
Noel, Stacey W.

Nolen, John R.

Nolen, Michael
Norris, Brian B.

Northrop, Robert C.
Nowell, Becky A.
O’Connell, Joseph
Onglao, Ana M.

Orgler, Raymond Jr.
Overholt, Shelley
Owens, R. Brian
Ozdemir, Aytekin
Ozment, Dennis W.
Palvadi, Priti
Palvadi, Rajarama M.
Parker, Jason D.

Parmar, Mona
Parmley, Patricia E.

Pate, Kimball B.

Patel, Harish
Patz, Brian
Paxton, Jason S.

Payne, Elisa M.

Peebles, Jody W.

Perrigin, Julie
Perry, Tamara L.

Peterson, Hilary A.
Peterson, Steve L.

Petty, Corwin D.
Petursson, Lisa M.
Phillips, Craig H.

Phillips, Kristina M.
Phooshkooru, Vijay R.
Pillow, James H.

Pitas, Grzegorz A.

Platt, Lucas Jr.

Plumley, Spencer G. Jr.
Pothuluri, Nomita J.
Prada, Stefan Alexand
Price-Barnes, Shirley
Priest, Dean B. Jr.
Pritchett, Daniel P.

Pyron, Luke D.

Queralt, Yvonne M.
Rajs-Nepomniashy, Roma
Ramiro, Mark
Rankin, Jay
Razmi, Syed Salman
Reddy, Shankari S.
Reynolds, Lisa S.

Rhodes, Robbie L.

Riche, Andrew
Rickwartz, Kevin
Roach, Milton III
Roberts, Russell Jr.
Robertson, Jonathon C.

224 • The journal

Volume 97

2000 Arkansas Medical Society Membership Roster

Residents

Rodgers, Chad T.

Shoppach, Jon Paul

Tilley, James B.

Rodgers, Michelle L.

Short, Walter

Tillomans, Tad

Roe, Diana L.

Siddiqui, Sayyadul M.

Touijer, Abdelkrim

Runion, Lance

Silas, David

Tran, Viet N.

Russ, Jennifer J.

Simmons, John P.

Triplett, Sheila B.

Russell, Eric, B.

Skelley, Christopher

Tumlison, Julie

Sadler, Jennifer M.

Skelley, Kimberly B.

Villamor, Shelaila

Sadler, Philip K.

Slabbert, Christiaan J.

Vuppala, Aparna

Sadziws, Laimis

Smith, Carol L.

Vuppala, Murthy S.

Said, Sufyan

Smith, LaNette

Wade, Kenneth

Samms, Donald

Smith, Todd P.

Waggoner, Bradley

Samuel, Meshach V.

Sokan, Babatunde

Waheed, Imran

Sauer, Kenneth M.

Sotomayor, Edgar A.

Walker, Randy

Sayani, Namrata

Spradlin, Timothy L.

Wall, Chris D.

Schad, Carla Jo

Sprinkle, Wesley

Walz, Brad H.

Schluterman, Keith O.

Srinivasan, Pattana

Ware, Gerald

Schneider, Daniel L.

Staley, Kelly

Webber, John C.

Schneider, Michael G.

Stamp, Jeffrey D.

Wells, Britton C.

Scoufos, Jennifer

Stark, Karen L.

West, Brian J.

Scurlock, Amy Martin

Steeger, Jennifer A.

West, Margaret

Scurlock, John P.

Stewart, Jason G.

White, Aaron E.

Sedaros, Robert S.

Stovall, Stephanie H.

Whiteside, Thomas F.

Shaffer, Kimberly K.

Strain, Lisa D.

Wiedower, Amy C.

Shah, Shailesh R.

Stuckey, Robert L.

Williams, Mark C.

Shaw, Allison

Swarup, Sachin

Williams, Tearani J.

Sheikholeslami, Mohammad

Tarpley, Jon

Williams, Veronica

Shinde, Abhijit

Thomas, Debra J.

Williams, Victor

Shipman Burton, Diana L.

Thomas, Wesley C.

Wilson, Robert B. Ill

Winkler, J. Mitch
Wise, James N.
Wiseman, Merle D.
Woods, Jennifer L.
Woods, Mark A.
Wooten, R. Gregory
Workman, James L. Jr.
Wright, Kristen N.
Yeh, Y. Albert
York, Andrea
You, Jean
Zeng, Wenjia
Zhang, Yue Hong
Zimmerman, Stacy
Zufari, Hazem

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Arkansas Financial Group Inc., The 184

Arkansas Foundation for Medical Care 180

Asti, William Henry, AIA 185

Autoflex Leasing 179

Bradford Marine and ATV 199

Central Flying Service 197

Farmers Insurance Group 198

Fiser Hummer 184

Guesthouse Inn 199

Hoffman-Henry Insurance Corp 197

Little Rock Medical Association 198

Maggio Law Firm 193

Mary Healey’s Fine Jewelry 183

Metropolitan National Bank 183

PhyAmerica Physician Services Inc 206

Professionals Advocate Insurance Co Inside front cover

Snell Prosthetic & Orthotic Laboratory 186

St. Vincent Health System 185

St. Paul Medical Services 204

State Volunteer Mutual Insurance Co Back cover

Special Publications

Editorial Art Director

Publisher

Irene Forbes

Brigette Williams

Advertising Art Director

Special Publications
Editor- in -Chief

Matt Stewart

Natalie Gardner

Advertising Coordinator
Kristen Heldenbrand

Assistant Editor
Christy L. Smith

Marketing Assistant
Mitzi Tiffee

Copy Editor
Donna Schratz

Database Administrator
H.L. Moody

Sales Manager
Stephanie Hopkins

Advertising Assistant
Greg Duszota

Account Executives
Jason Carson

▲ ARKANSAS BUSINESS

Liz Earlywine

PUBLISHING GROUP

Director of Design

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Olivia Farrell

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Jeff Hankins

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Allison Pickell

Executive Vice President
Sheila Palmer

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Jeremy Henderson

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Number 6

December 2000 • 225

ARKANSAS RETREATS

Photo: A.C. Haralson / Arkansas Department of Parks & Touri

DeGray Lake Resort

DeGray Lake Resort in Bismarck, a quiet island getaway surrounded by crystal waters and teeming with
recreational opportunities, is Arkansas’ only resort park.

Guests may enjoy any number of resort activities, including fishing, swimming and tennis. Or tee off at
the resort’s 18-hole, public championship golf course. The course offers a lighted practice and driving range
and a practice green.

In addition, the staff at DeGray Lake Resort State Park regularly host guided horseback trail rides,
scenic boat tours, nature walks and outdoor education programs. The park’s biggest event, Eagles Et Cetera
Weekend in January, celebrates the migration of bald eagles to DeGray Lake. Live eagles, hawks and owls
are used in demonstrations, but the highlight of the event is the many tours to see wintering bald eagles in
their natural habitat. For details, call (501) 865-2801.

Visitors who do not wish to camp may consider spending the night at DeGray Lodge, a 96-room newly
renovated facility that spans the shoreline of DeGray Lake. The rooms feature a view of either the woods or
lake, and all offer color cable television, room service and free accommodations for children 12 and younger.
Amenities include an outdoor swimming pool, gift shop and business center. Rooms are $70-80 per night.
Call (501) 865-2851 or (800) 605-5675 for lodge reservations.

DeGray Lake Resort State Park is off state Highway 7, northwest of Arkadelphia. For directions, call (501)
865-2108.

226 • The Journal

Volume 97

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Volume 97 Number7
January 2001

Journal

OF THE ARKANSAS MEDICAL SOCIETY

Winner of the ASAE Excellence in Communications Award

CONTENTS

FEATURES

236 Health Care Issues a Major Focus for Legislative Session

AMS members have an opportunity to make a real difference
this year during the Arkansas State Legislative session.

Read about AMS’ hot'button issues and what needs to be done.

239 Fighting for AMS

Dr. Scott Ferguson, a former state representative, tells about his
experiences as a lawmaker and why he thinks physicians should
become involved in the process .

Michael E . Dunn , a public affairs
consultant in Arlington Va. , urges
AMS members to get involved in the
political process.

— page 236

250 Endovascular Repair of Abdominal Aortic Aneurysms

In September 1999, the Food and Drug Administration
approved two devices for the endovascular repair of abdominal
aortic aneurysms. The endografts are placed from within the
arteries using fluoroscopic guidance.

DEPARTMENTS

232 Commentary

Jerry Kendall, MD

232 Letters to the Editor

235 What We’ve Done
For You Lately

241 Loss Prevention

245 Radiology Report
247 Surgery Report
255 People + Events

257 Arkansas Retreats

258 Index to Advertisers

New devices are now being used for
endovascular repair of abdominal
aortic aneurysms .

— page 250

Cover Photo: Kirk Jordan

Number 7

January 2001 • 231

COMMENTARY

LETTER

Politics and
Medicine

Jerry R. Kendall, MD

I have never been a political animal.
In fact, I would put politics dead last
on my list of preferred vocations.
However, I have voted in every election
for the past 45 years. My father bought
my poll tax ($1) the first year that I
voted and told me that if I had to skip a
meal, I should save some back in order
to exercise this privilege.

In our society, politics is the engine
that drives the government and is the
reason for social change, the success of the
economy, and the quality of life that we
enjoy. I believe that most politicians have
an altruistic reason for running for office.
They simply believe that they can make
a difference in our government.

However, they are like many
physicians: They are somewhat insecure
and have a need to be needed and to be
in a position of power. This may not be
on a conscious level, and they may use
this, as do many physicians, to do great
good. In our society, nothing is needed
more than dedicated, forward-thinking
people in our political system. However,
in many instances, it seems that the
decision to be made when voting is who
is the better of two poor choices.

This issue of The Journal focuses on
the coming legislative session and profiles
a former state representative, Dr. Scott
Ferguson, who merged a successful
medical practice with governmental
responsibilities. The medical community
is fortunate to have people like Dr.
Ferguson who will get involved and work
for the common good of us all.

Each of us, no matter how we feel
about the political system, should have
input to our representatives. Ever since
the time of the framing of the U.S.
Constitution, the argument has raged
over the role of elected officials. Some
said they should be emissaries of the
people who vote the people’s desires.
Another school said that officials should

be elected who, because of their
intellect, could make difficult choices
that the populace was unable to do.
Either way, they need to know the pulse
of the region that they represent, and
this is not possible without the
necessary dialog between them and
those whom they represent.

Every group and individual has a
prioritized wish list. The mark of a good
public official is how well he can walk
that tightrope and negotiate compromise
while providing a just and equitable
balance between all factions. Unfor-
tunately, there are times when doing the
right thing means political suicide.
Hopefully, when that occurs, our officials
will see the job as bigger than themselves
and have the integrity to do the right
thing as they see it without regard to the
prospects of re-election.

Sometimes we lose sight of the fact
that medicine is still a respected
profession. People still hold our opinions
in high regard. And as a group, we wield
an extraordinary amount of influence.
But that influence is hidden under a
bushel if we do not communicate with
our representatives. Lobbyist Lynn
Zeno and the Arkansas Medical
Society do an outstanding job on our
behalf, but how much more effective
would it be if each of us individually
contacted his or her representative on
important issues?

In the final analysis, the aim of
government officials and physicians
should be that common denominator
that binds us together: the benefit of the
doctor’s patients and the legislator’s
constituents. If that is the case, only
good medicine and good government
can ensue. ■

Dr. Kendall is a retired family
practioner from Camden. He is a member
of the editorial board for The Journal.

Dear Sirs:

The article by Christy Smith on
“The Big Easy” was of considerable
interest to me since I had experienced
many of the same things that were
described.

However, I have an additional
alternative to recommend for those who
are tired of the rat race of private practice
and frustrated by the perpetual conflicts
between duty to patient care and the red
tape of the current system.

At age 49, I took early retirement
from a very profitable diagnostic
radiology practice in Fort Smith,
primarily to avoid the administrative
hassles and conflicts I could see coming
in the near future. Those political and
economic conflicts were not what I
entered medicine for, and I was gratefully
out of the line of fire when the turmoil
in Fort Smith peaked a few years later.

I used retirement to sail (my
avocation of a lifetime) on the Atlantic,
Mediterranean and Caribbean Seas, dive
ancient wrecks, provide medical support
for nautical archeology field trips, and
to find out that all of these exotic things
really meant a whole lot less to me than
did the practice of medicine. Best of all,
I found a route to satisfaction within the
medical community that I had not been
able to explore from private practice:
academic interventional radiology.

After less than two years of
retirement, I began a full-fledged
vascular/interventional radiology
fellowship, learned to temporarily live
on a fellow’s pay, and started a career not
only doing clinical work — which was
focused and the most exciting in my
career — but also enjoying the
interactions with residents in a teaching
situation and interactions with others in
the research portion of the specialty.

After six exciting years full of events
that made medicine again important to
me, I feel fully qualified to recommend
this career track to others. Many of the
skills learned in private practice do have
application in the academic world,
which currently depends more than ever
(Continued on page 256)

232 • The Journal

Volume 97

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PHOTO: KELLY QUINN/TERRITORIAL RESTORATION

234 • The Journal

Volume 97

WHAT WE’VE DONE FOR YOU LATELY

COMMUNICATIONS COORDINATOR

Judy Hicks

EXECUTIVE VICE PRESIDENT

Kenneth LaMastus, CAE

ASSISTANT EXECUTIVE VICE PRESIDENT

David Wroten

EDITORIAL BOARD

Jerry Byrum, MD
Joseph M. Beck, II, MD
Lee Abel, MD
Samuel Landrum, MD
Jerry Kendall, MD
William Ackerman, MD

Pediatrics
Oncology
Internal Medicine
Surgery
Family Practice
Anesthesiology

EDITOR EMERITUS

Alfred Kahn Jr., MD

ARKANSAS MEDICAL SOCIETY
2000-2001 OFFICERS

Gerald A. Stolz, Jr., MD, Russellville
President

Joe Stallings, MD, Jonesboro
President-elect

Paul A. Wallick, MD, Monticello
Vice President

Lloyd G. Langston, MD, Pine Bluff
Immediate Past President

CarltonL. Chambers, III, MD, Harrison/Little Rock
Secretary

Dwight M. Williams, MD, Paragould
Treasurer

Anna Redman, MD, Pine Bluff
Speaker, House of Delegates

Kevin Beavers, MD, Russellville
Vice Speaker, House of Delegates

Joseph M. Beck, II, MD, Little Rock
Chairman of the Council

Established 1890. Owned and edited by the Ar-
kansas Medical Society and published under the di-
rection of the Council.

Advertising Information: Contact Stephanie
Hopkins, P.O. Box 3686, Little Rock, AR 72203;
(501) 372-2816.

Postmaster: Send address changes to: The Journal
of the Arkansas Medical Society, P. O. Box 55088,
Little Rock, Arkansas 72215-5088.

Subscription rate: $30.00 annually for domestic;
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The Journal of the Arkansas Medical Society
( ISSN 0004- 1858) is published monthly by the Arkan-
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Articles and advertisements published in The Jour-
nal are for the interest of its readers and do not
represent the official position or endorsement of The
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reserves the right to make the final decision on all
content and advertisements.

a What Have YOU Done
For Yourself Lately?

By David Wroten

This month I’d like to turn the tables a bit. Rather than describing
what the Arkansas Medical Society is doing to help Arkansas
physicians, I’d like to ask what you are doing to help yourself, your
patients and your profession? More to the point, what are you going to do?

In just a few short weeks the Arkansas General Assembly will convene
at the state Capitol in Little Rock. They will consider more than 2,000 bills
and resolutions. Nearly 200, or 10%, of those bills will be related to health
care. Some will relate to public health, some will relate to health insurance,
and some will likely relate to who can practice medicine. Some bills may
affect how you practice in your profession, and still some may affect how
and what you get paid. The bottom lines is, all will have some impact on
your patients.

The AMS has an effective governmental affairs program. We have a
history of successful legislative efforts, and we have a full-time lobbyist at
the Capitol every day. He happens to be one of the best in the business.

However, we are not legislators’ “hometown” constituents. We can
monitor the issues, provide truckloads of information and provide factual
testimony in legislative hearings. But, they want to hear from YOU.

Only YOU, the legislators’ treating physician or local neighbor, can
best describe the hassles of arguing over the phone with a third-party payor
for approval to treat your patients. YOU can best tell the legislator of the
frustration of telling a patient that his insurance company won’t pay for
treatment that you think is medically necessary. YOU can explain why
allied health professionals are not trained or qualified to diagnose. YOU
can describe the plethora of problems associated with smoking and why we
must concentrate on keeping tobacco out of the hands of our youth. The
list of issues where only YOU are considered the expert is endless.

Let’s face it. The legislature holds the key to who practices medicine
and to some extent, how. Are YOU willing to just sit back and let others
make decisions that affect you and your patients or are YOU willing to take
an active role in the process? Physicians are the most respected members of
the community. Your thoughts and opinions have a major influence on
legislators.

What are you going to do for yourself and your patients? Here are a few
things you can do to make a difference. First, read the legislative updates
we send to your home each week during the legislative session. When asked
to contact your legislator on specific legislation, do it immediately, keeping
in mind that it is you who needs his or her help. Make a commitment to
attend the AMS Day at the Capitol on Jan. 31. Nearly every legislator
attends our reception. When they ask, “Who is here from my district?” it
looks really bad when we have to say, “No one.”

By your active involvement, YOU can truly impact the future of
medicine and patient care. ■

Number 7

january 2001 • 235

Physicians Urged to
Take Active Role in
Political Process

By Christy L. Smith

The needs of Arkansas physicians and patients will con-
tinue to be ignored unless health care providers decide
to quit being victims, physicians were told at the Arkansas
Medical Society's 2000 Fall Meeting in late October.

Michael E. Dunn, president of Michael E. Dunn and Associates
Inc., a public affairs consulting company based in Arlington, Va., was
the keynote speaker. He delivered a quick civics lesson, outlining
how the American political system works and why it is important to
be involved, and coached the physicians on how to be effective
participants.

After Dunn completed his presentation, Lynn Zeno, director of
governmental affairs for the AMS, offered physicians an overview of
the issues the state Legislature might propose or consider when it
convenes in January.

About 75 member physicians attended the AMS meeting, held
Oct. 29 at the Embassy Suites in Little Rock. It is held every two years
to inform members about the issues that will most likely be proposed
or considered during the Arkansas General Assembly.

Here's a look at the presenters and what they had to say:

Making

^Count

Public affairs consultant Michael E. Dunn addressed
AMS members at the 2000 fall meeting.

Political Involvement

Dunn, who addressed the AMS 13 years ago when the
organization was considering whether to hire a governmental affairs
liaison, travels the country, helping corporations and trade and
professional associations become more politically effective through
political action committees, grassroots lobbying programs and political
education programs.

At the 2000 Fall Meeting, Dunn reminded physicians that issues
that affect them are often determined by legislators who have no
background in health care and that physicians are the most qualified
to convey their needs and the needs of their patients to lawmakers.

The Power
of the Pen

Tips for
Writing an
Effective Letter
to Your Legislator

• Use the title "Honorable" to show respect for our system of government and those who died
defending it.

• Always include your congressman’s office or suite number and the number of his building in
the address line. This ensures proper delivery of your letter. If you do not know the specific
address, call and find out.

• It is appropriate to call a legislator by his first name only if you know him personally.

If you are writing about a certain piece of legislation, cite the bill number, the bill title, the

subcommittee that is considering the bill, what action is pending on the bill and what
specific issue you want the congressman to address. If you are not specific, you will
be disappointed with the response.

• Never use a threatening or rude tone. This approach is counterproductive.

• Keep your letter short and to the point. No one is going to read it if it’s longer
than one page.

236 • The Journal

Volume 97

Savvy Physicians

Arkansas physicians can now contact their state
and federal lawmakers with the click of a mouse.
The Arkansas Medical Society's Web site now
features a link to the American Medical Association's
Grassroots Action Center.

This feature allows member physicians to look
up the names and contact information of their state
and federal lawmakers and then send them an
electronic message. Physicians simply enter their
ZIP codes in the appropriate field and hit the search
button. Then a list of their lawmakers appears.

By clicking on the name of a lawmaker, physicians may access a biography
and photo. Most lawmakers have an e-mail address as well as a snail mail address,
so physicians may send an electronic message. If a lawmaker does not have an e-
mail address, physicians may send a traditional letter.

But would a lawmaker take an e-mail as seriously as he would a handwritten
letter?

Dr. Scott Ferguson, a diagnostic radiologist from West Memphis and former
state representative, seems to think so.

“I think it is very effective," he said at the 2000 Fall Meeting. “They’ll read [the e-
mails] if you personalize them.”

The AMS Web address is www.arkmed.org. Click on the Grassroots Action
Center icon to begin accessing the database of legislative information.

Internet

Fie urged physicians to become friendly
with their legislators and their legislators'
staffs, to write letters to their congressmen,
to donate to the campaigns of candidates
who might be sympathetic to physicians'
needs, and to remain informed about health
care issues being considered at the state and
federal levels.

"Whether you like politics or not is
immaterial," he said. "The future of medicine
here in the United States will be determined
by decisions made by Congress and your state
Legislature."

If physicians do not become involved in
the policymaking process, they will no longer
have control over the way they practice
medicine, Dunn said.

"There will be more and more people
telling you what to do," he said.

Most Americans "don't have the
foggiest idea" how public policy is made,
he said, but "my goal is to make sure that
what you say to your lawmaker makes a
difference in how that lawmaker decides to
vote."

According to Dunn, physicians need to
remember two key points about the political
system before they can be effective
participants: Compromise plays an integral
role in determining public policy, and those
who control the political environment will
control the way policy issues are determined.

When legislators compromise on issues,
there is always a winner and a loser, Dunn
said.

"There has never been a bill enacted
into law that universally benefited everyone.
Every time a legislator determines a matter
of public policy, there will be people who
win as a result of that law, and there will be
people who lose as a result of that law," he
said.

If physicians want to be winners in the
American political process, they must make
their needs and views known to their
legislators, Dunn said.

"We live in a highly competitive, special-
interest democracy. A fatal flaw of a
representative democracy is that it only
represents those who get involved. You are
either a player or a victim," Dunn said. "This
is a call to action to get ready for January. If
you are not ready for January, you are not
going to like what happens to you."

In addition to being president of Michael
E. Dunn and Associates, Dunn is president
of Public Affairs Video Enterprises Inc, a

media communications corporation
dedicated to producing innovative public and
governmental affairs video programs for the
business, trade and professional
communities.

Fie is on the board of directors of the
Public Affairs Council in Washington, D.C,
and the Arlington Free Clinic, which provides
health services to the needy.

Before establishing his own companies,
Dunn was director of government relations
services for the Public Affairs Council, the
national professional organization for
business public affairs executives.

Dunn also was legislative assistant for
two former U.S. representatives — David
Pryor, D-Ark, and G.V. "Sonny" Montgomery,
D-Miss. Before moving to Washington 26
years ago, Dunn taught political science at
the University of Arkansas at Monticello. He
is a native of Magnolia. Dunn and his wife,
Mary, have one daughter, Meredith.

Health Care Issues

In January, a new group of state and
federal lawmakers will convene, Zeno said.
Many of the thousands of proposals that will

be considered by lawmakers next year will
affect how physicians practice and what
services patients may obtain, he said.

"Ninety-nine percent of all medical issues
are black and white. They are either good for
patients and doctors, or they are bad," he said.

Some of the health care issues that may
be considered at the state level are prompt
payment, prohibition of "all products" clauses,
fee schedule disclosure, drug recycling in
nursing homes, smoking prohibitions in public
places, gunlock requirements for stored
firearms, bottle rocket prohibition, prohibition
of minors in pickup truck beds and repeal of
the soft drink tax, Zeno said.

"Many of these are repeats, and we fight
them every two years," he said.

Zeno said Arkansas physicians are
concerned about prompt payment because
some insurance companies take as long as
120 days to reimburse physicians for their
services, whereas the regular consumer is
expected to remit payment for a bill within 30
days.

"Prompt payment is the biggest issue I
hear about from members," he said.

Zeno said he would like to see approval

Number 7

January 2001 • 237

of legislation requiring third-party payers to
remit payment for electronically submitted
"clean claims" within 30 days and for
manually filed "clean claims" within 45 days.

He said third-party payers should request
additional information for a "non-clean
claim" within 30 days and then remit
payment for the claim after 30 days. A penalty
also should be assessed against insurance
companies that fail to pay claims in a timely
manner, he said.

Another insurance issue is the all-
products clause, which, in contracts between
physicians and third-party payers, stipulates
that if a physician signs up for one of an
insurance company's programs, he auto-
matically signs up for all the programs, Zeno
said. The medical Society will most likely push
for a prohibition of these contractual
arrangements, he said.

The society also will support any attempt
to require insurance companies to publicly
disclose the dollar amount they will reimburse
a physician for specific services, proposals to
require nursing homes to use the unopened
drugs of a deceased patient rather than discard

Dunn, Lynn Zeno, AMS director of gover-
mental relations; and Dr. Joe Stallings, AMS
president-elect; at the fall meeting.

them, and measures to prohibit smoking in
public places such as restaurants, Zeno said.

Public health issues such as gunlock
requirements and prohibition of bottle
rockets and of minors' riding in truck beds
are likely to be raised during this year's
legislative session, Zeno said.

And while the society would support
such proposals to ensure the safety of
Arkansans, they would probably not fare well
in the Legislature, he said.

"There are four things you don't mess
with in the state Legislature — dogs, pickup
trucks, guns and fireworks," Zeno said.

And while there are plenty of proposals
the medical society would support, a repeal
of the soft drink tax is not one of them, he
said.

In 1992, the state Legislature passed a
2-cent tax on all bottled and canned soft
drinks to help support the state's Medicaid
trust fund. The tax generates about $50
million a year. The federal government
matches it, 3 to 1, generating about $200
million annually, but the Medicaid fund still
comes up short, Zeno said.

A tobacco settlement that Arkansas
voters approved Nov. 7 will help alleviate that
Medicaid shortfall by pouring about $17
million into the fund annually, Zeno said. Some
opponents of the soda tax may argue during
the next legislative session that it is time to
repeal it because an alternative source of
Medicaid funding has been approved, he said.

"The AMS would be opposed to any
proposal that might jeopardize funding of
the Medicaid trust fund." Zeno said.B

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238 • The Journal

Volume 97

Meet Our Members

Scott Ferguson, MD

By Christy L. Smith

Dr. Scott Ferguson , a former
state representative from West
Memphis , ivas often the
“go-to man" when it came
to health care issues up
before the state
Legislature .

Number 7

Dr. Scott Ferguson knows what it’s like to be the only doctor
in the house.

The 49-year-old diagnostic radiologist from West Memphis
served two terms in the state House of Representatives. Because
he was the only physician serving in the House from 1992-98,
other legislators went to him for advice about health care issues.

“I was the only freshman member of the Public Health, Labor
and Welfare Committee because I was viewed as an expert in
that area,” Dr. Ferguson said. “The other committee members
looked at me to find out how a bill would impact patients.”

Of course, being the answer man can be stressful, Dr. Ferguson
acknowledged.

“I really had to get up to speed quick,” he said. “I knew from
my everyday working experience how [laws] would impact
patients, but I didn’t know the intricacies of health care policy. I
was thrown into the arena, and I had to learn. It was very
stimulating and very educational.”

Dr. Ferguson’s interest in politics and medicine was culled
from his parents, he said. Joyce Ferguson Wyatt was a grassroots
activist who became mayor of West Memphis, and
Thomas Murray was an obstetrician and
gynecologist who encouraged his son t
pursue a career in medicine.

“My mother, back in the ’60s, led th
fight for fluoridation of water. She becam<
mayor of the town in the 70s and was th(
first female mayor of a first-class city,” he
said.

Dr. Ferguson completed his premed
requirements at Memphis State Uni-
versity and graduated from American
University of the Caribbean in Montserrat,

British West Indies, in 1981 . He completed
a one-year rotating internship at Lloyd
Nolan Hospital in Birmingham, Ala., and i
diagnostic radiology residency at Baptii
Memorial Hospital in Memphis. He bega

practicing at Outpatient Radiology Clinic in West Memphis in
1985.

Dr. Ferguson said he entered the political arena in the early
1990s because managed care caused him to stop seeing about
40% of his patients whose insurance companies required them
to see doctors in Memphis.

“I was interested in making sure that people in our town
could see the doctor of their choice,” he said. “I was encouraged
that the state Legislature is a place where you can have an
impact.”

Dr. Ferguson credits his election victories to the support
he received from the Arkansas Medical Society, his fellow
physicians and his local constituents. During his tenure in the
Legislature, Dr. Ferguson sponsored the 1 995 “any willing provider”
bill, which allowed patients to go to the doctor of their choice.
The measure was unanimously approved in the Legislature but
was later overturned by a federal court, Dr. Ferguson said.

In 1997, he sponsored the Health Care Consumer Act. The
measure prohibits gag clauses in insurance contracts, gives new

mothers the choice of remaining in the
hospital for 48 hours rather than being
discharged after only one day, and requires
insurance companies that pay for a
mastectomy to also provide coverage for
reconstructive surgery or prosthetic devices,
among other provisions.

Also in 1997, Dr. Ferguson co-
sponsored legislation to establish ARKids
First, a program designed to insure the
children of working families who cannot
afford to purchase health insurance, and the
Comprehensive Flealth Insurance Pool for
high-risk individuals who cannot otherwise
get insurance.

Dr. Ferguson said his stint in the House
of Representatives has been the “single
greatest learning experience” of his life so
far.

“I had a great experience in the House
of Representatives,” he said. “I was meeting
people from all walks of life, from all over
the state, who had different perspectives
and different ideas.”

Physicians who think politics and
medicine are at opposite ends of the
spectrum are mistaken, Dr. Ferguson said.

“As doctors, we try to take care of

patients. We try to heal people and make
them better,” he said. “In the Legislature,
you can have such an impact on the whole
state, on the people’s needs. It’s a slower
process, hut it certainly has a greater
impact on a larger number of people.”

Dr. Ferguson left the state House to
try national politics. He competed against
U.S. Sen. Blanche Lincoln, D-Ark., in the
1 998 Democratic primary.

Although he was unsuccessful in that
attempt, he said it is important for him —
and his colleagues — to remain involved
in the legislative process.

“There are a lot of decisions made
every day that directly affect patients and
the medical community that are made by
people who have no working knowledge
of medicine. Legislators depend upon the
Arkansas Medical Society and their local
doctors to educate them.” he said. “So
often, doctors want to take care of patients
and then be left alone. But I think we’ve
seen what affect that attitude has. Things
will go contrary to good public health; things
will go contrary to our patients.”

Dr. Ferguson said he will he keeping
an eye on several issues during the coming

Arkansas General Assembly hut that the
soda tax is foremost on his mind.

“The tobacco referendum just passed,
and it is going to do a lot of wonderful
things for health care, but there is a fear
among people involved with politics and
the medical community that there will be
a push to repeal the soda pop tax,” he said.

The 2-cent tax, approved by the
Legislature in 1992 as a levy on bottled
and canned soft drinks, generates about
$50 million annually for the state
Medicaid fund. Those funds are matched
3-to-l by the federal government, so a
repeal of the soda tax could cost the state
$200 million, Dr. Ferguson said.

Dr. Ferguson has been a member of
the Arkansas Medical Society since 1985.
He is chairman of the Society’s govern-
mental affairs committee, which decides
how the Society’s political action
committee will spend its money and what
issues the Society will get involved in.

Dr. Ferguson’s wife, Deborah Fer-
guson, is a dentist in West Memphis. Dr.
Ferguson and his wife have three children
— Catherine, an 18-year-old high school
senior; Scott Jr., 15; and Caroline, 9. ■

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240 • The Journal

Volume 97

LOSS PREVENTION

Trauma-What Were the Facts?

J. Kelley Avery, MD

Case Report

On an icy road early one morning while
driving his wife to work, the husband suddenly
encountered a line of cars involved in an
accident. He swerved to avoid the car in front
of him, skidded sideways, and was struck
broadside by a car following him. Both he and
his wife were taken to the nearest hospital
emergency department. She was treated for
minor injuries and discharged. Her husband,
however, was more seriously injured.

The evaluation of the husband was done
initially by an ED physician who was
finishing up his shift, and it was completed
by the physician’s relief, who had just arrived
in the ED.

The patient’s complaints were chiefly of
pain and swelling of the right hand, some
epistaxis and facial contusions. The past
medical history revealed emphysema, but the
patient denied having any other medical
problems.

The examination revealed some bleeding
from the nose, which had largely stopped, and
some swelling and tenderness of the face. The
notes reveal that the patient wore upper and
lower dentures. The remainder of the
assessment was unremarkable except for the
swelling, tenderness and crepitation over the
dorsum of the right hand. At the time of the
evaluation, the patient was wearing a
Philadelphia collar that had been put on him
by the paramedics at the scene. Vital signs were
stable, and the patient was sent to the X-ray
department for studies of the skull, cervical
spine and right hand.

He then complained of feeling faint and
stated, “I’m going to pass out.” After receiving
IV fluids, he seemed to feel much better. The
CT scan of the head was reported negative, as
were the X-rays of the cervical spine. The hand
showed displaced fractures of the second and
third metacarpals, and the orthopedic surgeon
on call was notified.

Since the patient seemed stable and the
roads were very dangerous, both the ED
physician and the orthopedic consultant
agreed the patient would be admitted to the
outpatient service for a short stay so that he
could be more thoroughly evaluated when
getting to the hospital would be safer for the
orthopedic surgeon. Later that day, the surgeon
did come and scheduled the patient for
reduction and pinning of the fractures the
following morning.

The record does not contain an
examination hy the surgeon, hut the nurse
anesthetist’s evaluation revealed no contrain-
dication to general anesthesia. The examin-
ation did reveal a statement, “Dentures or
capped teeth-edentulous.”

Reduction and pinning was accomplished
without incident under general anesthesia,
postoperative assessments were carried out
appropriately, and the patient was discharged
from the recovery room. The patient
complained of pain in his left knee, but X-rays
were negative. The nurse removed a small
piece of glass from the patient’s gum line. There
was some disagreement as to whether or not
the nurse notified the surgeon about this. The
patient was then discharged with appropriate
instructions.

The patient’s wife stated she tried to
contact the surgeon on several occasions
because her husband was having difficulty
swallowing but that she was unsuccessful. She
had been given instructions at the time of
discharge as to how to contact the doctor.
There was no resolution to this problem as far
as the patient was concerned.

However, the patient, as instructed,
returned to the surgeon’s office two days after
being discharged from the hospital. The
patient’s complaints were principally that he
had some bleeding through the dressing on the
hand and that he was having more difficulty
swallowing.

Number 7

January 2001 • 241

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In the office note, the surgeon
reported the changing of the dressing
and stated, “Comorbid conditions
include lacerations about the mouth
treated by the ED physician. The
patient apparently strained his neck,
has some swallowing difficulty ... I’d
like to monitor him for this and
perhaps obtain appropriate studies if
his symptoms of swallowing difficulty
continue.”

During the
next 24 hours,
the patient devel-
oped some in-
creased difficulty
breathing and
swallowing, and
his wife was told
by the surgeon’s
office to take him
to the hospital
immediately.

He was ad-
mitted to a dif-
ferent hospital
(the surgeon’s pri-
mary hospital) on
this occasion. He
was nauseated,
weak, somnolent
and hallucinating.

His shortness of
breath and dizzi-
ness had worse-
ned since the
office visit of the day before. His blood
pressure was 90/40 mm Hg, he was
dyspneic, and he had a poor urinary
output.

On examination, a firm swelling in
the left side of the neck was found, with
ecchymoses extending inferiorly into
the auxiliary area. Further X-ray studies
revealed retropharyngeal air extending
over the area of the neck where there
appeared to be a “radiopaque foreign
body which bridges the area of the
retropharynx and extends into the
pharynx itself.”

He was in a state of septic shock,
which progressed to multisystem failure
requiring aggressive antibiotic and
fluid/electrolyte support. Renal failure
indicated the need for renal dialysis.

examination,
a firm
swelling in
the left side
of the neck
was found,
with

ecchymoses
extending
inferiorly into
the axillary
area.

242 • The Journal

Volume 97

During the severe hypotension
associated with the sepsis, the patient
developed severe ischemic gangrene of
the extremities, resulting in the
amputation of one hand, three fingers
on the other hand, and both legs
below the knee. The patient survived
and was discharged after about three
months in the hospital.

While in the hospital during the
two admissions, the patient was treated
by two ED physicians, a radiologist, an
orthopedic surgeon, an internist, an
infectious-disease specialist and a
nephrologist.

Lawsuits for failure to diagnose the
esophageal tear were filed against the
orthopedic surgeon, the anesthes-
iologist and the ED physician at the
first hospital to which the patient had
been admitted.

A thorough investigation revealed
significant problems for all the
physicians sued. A jury trial of these
complaints seemed out of the question
because of the extensive damage that
resulted to the patient during this
extremely critical disease process, and
the sympathy that would naturally be
present. The settlement for all
physicians combined was in the high
six figures.

Loss Prevention Comments

The details of the initial evaluation
were very poorly documented. The
issue of the dentures was not part of
the record. Both the patient and his
wife contended that they had told all
the physicians and the anesthetist of
his “swallowing his teeth” and his
difficult removal of them from deep in
his throat using his fingers. Although
this fact was nowhere documented in
anybody’s record, the bleeding from
the mouth and the difficulty
swallowing were mentioned in
multiple places by several caregivers.

The first X-ray of the cervical spine
revealed the retropharyngeal air, which
was missed by the radiologist. The
only physician note about the
swallowing difficulty was that of the
orthopedic surgeon, who, on the visit
two days after the initial discharge,

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Number 7

January 2001 • 243

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documented the complaint and
speculated about a follow-up by
another specialist. However, during the
visit, he did not look at the patient’s
mouth or throat.

The proof developed after the
lawsuit was filed indicated that both
the anesthetist who did the initial
preoperative evaluation and the
anesthesiologist who put in the
endotracheal tube should have seen
the lesion in the throat. Had the
surgeon examined the patient’s mouth
and throat two days before his last
admission, he might well have seen the
injury in the throat and effected an
appropriate intervention.

Even without the swearing contest
of the patient and his wife with all the
physicians involved, there was
enough expert testimony putting all
of them outside an acceptable
standard of care. The radiologist did
not report the retropharyngeal air that
was subsequently seen on the initial
films. The ED physician in the first
admission note did not document
any assessment of the throat or
mouth as a result of the history of
“swallowing his dentures.” The
surgeon paid more attention to the
swallowing problem than did anyone
else, but he did not look into his
patient’s mouth. All this, in the face
of consistent testimony of the patient
and his wife that they told the story
of his swallowing his teeth multiple
times, was extremely weak.

It is almost a rule in medical
liability litigation that a swearing
contest between the physicians and the
injured patient is consistently lost by
the doctor in the absence of
contemporaneous documentation to
the contrary. ■

Reprinted from a November 1999
issue of Tennessee Medicine. The Case
of the Month is taken from actual
Tennessee closed claims. An attempt is
made to fictionalize the material in order
to make it less easy to identify. If you
recognize your own case , please be assured
that it is presented solely for the purpose of
emphasizing the issues presented.

244 • The Journal

Volume 97

Allergic Fungal Sinusitus
Has Become Common

AUTHORS: Charles M. Bower, MD — Tracey D. Stewart, MD
EDITOR: Steven R. Nokes, MD

History

A 10-year-old girl presented with
severe headaches, nausea, vomiting and
dehydration. She was afebrile. A CT
scan of the head was perfonned (Fig. 1
&. 2), which prompted an MR scan (Fig.

3&4).

Findings

The CT scan reveals a 4-by-3'Cm

expansile mass centered in the
sphenoid sinus, which is hyperdense
and does not enhance. On MR imaging,
the sphenoid mass has a laminar
appearance with an intermediate signal
intensity on Ti weighting and decreased
signal intensity on T2 weighting.
Peripheral rim enhancement is noted,
with enhancing tissue extending

through the sphenoclinoid synchon-
drosis along the clivus.

Diagnosis

Allergic Fungal Sinusitis (AFS)

Discussion

Fungal sinus disease, once con-
sidered uncommon, has increased

Fig. 1. CT scan without contrast.

Fig. 2. CT scan with contrast.

Number 7

January 2001 • 245

Fig. 3. Sagittal T2 weighted (4000/80). MR of the brain
without contrast.

Fig. 4. Sagittal Ti weighted (500/1 2). MR of the brain with
contrast.

dramatically over the past two decades.
The classification scheme recently
changed with an increase in the
understanding of the disease. Fungal
sinusitis is broadly divided into
invasive and noninvasive forms.
Invasive fungal sinusitis includes acute
fulminant fungal sinusitis, granulo-
matous invasive sinusitis and chronic
invasive fungal sinusitis. Invasive
fungal sinusitis may be rapidly
progressive and fatal. Noninvasive
fungal sinusitis is subdivided into
fungus ball and allergic fungal sinusitis,
both of which are rarely fatal.

AFS is now thought to be the most
common form of fungal sinusitis. Nasal
obstruction, rhinorrhea and facial
pressure are common syumptoms. Most
patients have obvious nasal polyps.
AFS is a disease of young adults (most
commonly 20- to 30-year-olds) who
live in warm, humid climates. It is
characterized by the presence of alien
gic mucin in the involved sinus.
Allergic mucin is composed of lam-
inated collections of intact and degen-
erated eosinophils, Charcot-Leyden
crystals, cellular debris and hyphae
which do not invade mucosa. Origin-
ally thought to be solely caused by
Aspergillus, several other common

fungi including Curvularia, Bipolaris,
Pseudallescheria and Fusarium have
been implicated.

AFS continues to be under-
diagnosed. CT and MR play an im-
portant role in suggesting the disease,
allowing prompt and effective therapy.
Treatment differs from other forms of
fungal sinusitis and involves func-
tional endoscopic surgery with adjunc-
tive systemic and intranasal steroids to
decrease the abnormal immune
response. Systemic antifungal agents
play no role in the treatment. Allergen
immunotherapy to downregulate the
production of fungus-specific immun-
oglobulin E holds promise. Recurrence
of polyps is not uncommon.

CT reveals a hyperdense mass in
the affected sinus due to a com-
bination of heavy metals (iron and
manganese), calcium and densely
packed hyphae. The sinus is almost
invariably totally opacified and
expanded. Extension into adjacent
structures occurs in 20%, usually
intracranial or intraorbital.

MR demonstrates low signal on T2
weighting due to an absence of mobile
protons and the heavy metals. This
appearance is not specific, however,
and occurs in any inspissated,

chronically obstructed sinusitis. The
signal characteristics can mimic normal
aeration at MRI, resulting in gross
underestimation of disease.

Differential diagnosis would include
chordoma, sinonasal meningioma or a
sarcoma with a chondroid matrix. All
of these would be expected to be less
homogeneous on CT and enhance to
some degree. The laminar appearance
on MR with peripheral enhancement
would be highly unlikely in these
tumors. ■

Dr. Nokes is with Radiobgy Consultants
of Little Rock. Dr. Bower is with the
University of Arkansas for Medical Sciences
and Arkansas Children’s Hospital. Dr.
Stewart is in private practice.

References

1. Mukherji SK, Figueroa RE,
Ginsberg LE, et al: Allergic fungal
sinusitis: CT findings. Radiology
1998; 207:417-422.

2. Fatterpekar G, Mukherji SK,
Arbealez A, et al: Fungal diseases
of the paranasal sinuses. Sem in
US, CT and MRI 1999; 20: 391-401.

3. Deshazo RD, Chapkin K, Swain
RE: Fungal sinusitis. N Engl J Med
1997; 337: 254-259.

246 • The Journal

Volume 97

Open versus Thoracoscopic
Removal of Left-Sided
Mid-Esophageal Leiomyoma

A.H. Rusher, MD, FACS — Kim Davis, MD — David Phillips, MD — L. Wiggins, MD, FACS

Introduction

Although esophageal leiomyomata are benign tumors,
it is generally recommended that they be surgically removed
due to the associated morbidity. The most common
complaints as this benign smooth muscle tumor enlarges
are dysphagia, retrosternal pain, regurgitation, weight loss
and vomiting. Traditionally, either a right or left
thoracotomy was an acceptable approach, depending on the
location of the tumor. The literature recommends that
upper- and mid-esophageal tumors be approached with a
right thoracotomy and that lower esophageal tumors be
approached from the left.1

More recent articles have explored the use of
thoracoscopy for removal of these benign tumors.2 In most
cases of simple leiomyoma, it is reportedly safe and effective
to remove these tumors thoracoscopically.3 Even using the
thoracoscope, the recommendation has remained the same
for the side of approach for the level of tumor.4 This case
presentation is to suggest that left-sided esophageal
leiomyomata may be approached from a left-sided
thoracotomy or thoracoscopy from the lower esophagus up
to the level of the aortic arch.

Case Report

The patient is a 53-year-old white female who presented
with the complaint of dysphagia worsening over two to three
months. She also reported some history of reflux. The
patient underwent EGD, which was normal except for some
extrinsic compression of the mid-esophagus. She had a CT

scan that showed an esophageal mass in the upper mid-
esophagus. A subsequent barium swallow revealed a smooth
3 cm lesion based on the left lateral aspect of the esophagus.
Because of the classic appearance, it was presumed to be a
leiomyoma.

Due to her symptoms, the decision was made to proceed
with surgical removal of the mass. With the left-sided
location, there was concern about the ease of removal if a
right-sided approach was used. The concern about a leftward
approach was the involved anatomy, namely, the bronchus
and aorta. After consideration, the decision was made to
perform a left thoracotomy.

Procedure

The patient was intubated using a double lumen
endotracheal tube using fiberoptic bronchoscopy to ensure
correct placement. She was then placed in the left lateral
position. The fifth rib was then resected in the subperiosteal
plane. The left lung was then deflated with the subsequent
natural separation of the space between the bronchus and
aorta. The bulging leiomyoma was then easily visually
identified. Her mediastinal pleura was then divided over
the mass. The leiomyoma was easily enucleated using both
blunt and sharp dissection without damage to the mucosa.
Because the dissection went so smoothly and the mucosa
was obviously intact, the esophageal lumen was not injected
with dye.

The muscular layer was then reapproximated and a

January 2001 • 247

Number 7

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pleural flap was performed for
reinforcement and coverage. A chest
tube was then placed. The patient was
extubated and taken to the recovery
room in stable condition. She was
placed in the ICU overnight and
transferred to the floor the next day.
She progressed well and was able to eat
a regular diet and was discharged home
on the fourth postoperative day.

A frozen section was not obtained
intraoperatively because the tumor was
relatively small and had the
characteristic features of a leiomyoma.
The literature does suggest that large
tumors go for frozen section. Her final
pathology report revealed a 3.1-by-2.2-
by- 1.6 cm benign leiomyoma.

Discussion

Leiomyomata are the most common
benign tumors of the esophagus, making
up 80% of the benign tumors of the
esophagus.3 According to one study, the
mean longitudinal size in adults is 4.9
cm.5 The average patient age is 38 years.
Ninety percent of the tumors found in
the lower two-thirds of the esophagus.
They are twice as common in males.
The origin is smooth muscle, and the
tumors are usually oval in appearance.
They are solitary and encapsulated.
The accepted workup includes barium
swallow, CT and EGD. A biopsy
during EGD is not recommended
because in the case of leiomyoma,
successful enucleation without esopha-
geal resection is dependent upon
mucosal integrity. Recently, endoscopic
ultrasound has been suggested as a useful
tool for evaluating these tumors.5,6
Surgery is recommended when these
tumors are discovered, especially when
symptomatic, because of the progressive
nature of the symptoms. A right- vs.
left-sided approach depends on tumor
location. Open thoracotomy versus
thoracoscopy should be considered,
depending on tumor size and location.
One study suggested that inserting an
esophageal balloon intraoperatively
aided enucleation.6

In this case, a left thoracotomy was
chosen because of concern for adequate
exposure at the mid-upper esophageal
location of the leiomyoma. In

248 » The Journal

Volume 97

retrospect, this could easily have been
performed thoracoscopically, even up
to the level of the aortic arch, because
the airway is easily displaced forward
with desulfation of the lung. In the
past, a right approach has been
suggested for middle to upper
esophageal leiomyomata, whether on
the right or left esophageal wall.

Presumably, this is due to ana-
tomical concerns. However, as is
demonstrated in this case, with
desulfation of the lung, the bronchus is
easily displaced forward and a leftward
approach can be safely performed up to
the aortic arch. ■

Dr. Davis is a third-year family
practice resident at AHEC Northeast in
Jonesboro, where Drs. Rusher, Phillips
and Wiggins are staff surgeons at St.
Bernards Regional Medical Center.

Bibliography

1 . Schwartz. Principles of Surgery,
McGraw Hill, 1994.

2. Bonavina L, Segalin A, Rosati R,
Pavanello M, and Peracchia A:
Surgical therapy of esophageal
leiomyoma. Journal of the
American College of Surgeons,
Sept. 1995, Vol. 181, PP. 257-262.

3. Bardini R, Asolati M:
Thoracoscopic resection of benign
tumors of the esophagus.
International Surgery, 1997; 82:5-6.

4. Taniguchi E, Kamiike W, Iwase K,
Nishida T, Akashi A, Ohashi S, and
Matsuda H: Thoracoscopic
enucleation of a large leiomyoma
located on the left side of the
esophageal wall. Surgical
Endoscopy, 1997;11:280-282.

5. Watanabe M, Kuwano H, Sadanaga
N, Ikebe M, Mori M, and
Sugimachi K: Leiomyoma of the
esophagus with special reference to
the characteristics of this tumor in
teenagers. Hepato-Gastroenterology
44, 1997, Pp. 164-169.

6. Mafune K, Tanaka Y:
Thoracoscopic enucleation of an
esophageal leiomyoma with balloon
dilator assistance.” Surgery Today,
1997. Vol. 27, pp. 189-192.

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Number 7

January 2001 • 249

SCIENTIFIC ARTICLE

Endovascular Repair of
Abdominal Aortic Aneurysms

Michael F. Knox, MD, FACR, — Fred A. Meadors, MD

In September 19 99, the Food arid Drug Administration approved two devices for the endovascular repair of abdominal
aortic aneurysms. The endografts are placed from within the arteries using fluoroscopic guidance. The minimally invasive
technique is performed using bilateral femoral artery cut-downs and has significant advantages over open surgical repair,
including a reduction in morbidity, hospital stay and blood loss, with a much quicker return to normal activities. Endoleaks
are the main complication following endovascular repair, and close follow-up of patients with CT is recommended to
confirm adequate exclusion of the aneurysm.

Fig. 1. Spiral CT scan shows a 4.7 cm infrarenal AAA (arrow).

Fig. 2. 3 cm right common iliac artery aneurysm (arrow).

Introduction

The prevalence of abdominal aortic aneurysm (AAA)
is estimated to have tripled over the last 30 years,1 and there
are approximately 1.5 million Americans with an AAA.
About 190,000 new cases are diagnosed annually, and
45,000 undergo surgical repair each year in the United
States. It is estimated that 15,000 Americans die each year
of AAA rupture, making it the 13th leading cause of death
in the United States overall and the 10th leading cause of
death in American males.

It is known that the five-year risk of rupture is only 2%
if an aneurysm measures less than 4 cm in diameter, but the
five-year risk increases to 25-41% if the aneurysm is greater
than 5 cm in diameter. On average, aneurysms tend to
enlarge by 0.5 cm per year.1

Most AAA’s occur in patients older than 55, and there
is a strong male predominance. Significant risk
factors include a family history of aneurysms,
generalized atherosclerosis, advanced age, hyper-
tension and cigarette smoking.

Although most aneurysms are asymptomatic,
some may present as a pulsatile mass or may cause
pain. AAA’s are usually diagnosed on routine
physical exam but are also discovered fortuitously
on ultrasound, CT, MRI or arteriography done for
other reasons.

AAA Treatment

Since the 1950s, surgical management of
AA A’s has been the treatment of choice; how-
ever, mortality rates of up to 7.3% and significant
morbidity in 15-30% of surgically treated patients
has prompted investigators to develop a less
invasive approach in the treatment of AAA’s.2 In

250 • The Journal

Volume 97

1991, Parodi presented his experience with a homemade stent
graft device constructed from large Palmaz stents and fabric,
used to successfully exclude AAA’s in five patients.3

Since that time, other investigators have worked with
different endograft designs, and worldwide experience with the
different devices is accumulating rapidly. The terms
“endovascular” and “endograft” refer to grafts implanted from
within the blood vessels via minimally invasive techniques using
X-ray imaging guidance. The endografts are contained within
delivery catheters and are deployed into position using catheter
and guidewire techniques. Instead of being sewn into position
as in an open repair, the endografts are anchored by stents and/
or hooks. They also are usually balloon-dilated to secure fixation
and apposition to the native arterial wall.

In September 1999, the FDA approved two endovascular
devices for clinical use in the repair of AAA’s: ANCURE
(Guidant Cardiac & Vascular Surgery Group, Menlo Park,
Calif.) and AneuRx ( Medtronic/ AVE, Sunnyvale, Calif.). There
are at least seven other endograft devices in clinical trials in the
United States. At St. Vincent Infirmary Medical Center in Little
Rock, we have developed an endovascular program and have
gained early experience with the bifurcated ANCURE Endograft
in our patients.

Endovascular Repair

The prime objective of endovascular repair of AAA’s is the
same as in surgical repair, i.e. to eliminate the risk of aortic mpture
by sealing, or excluding, the aneurysm from aortic blood flow.
Secondary objectives include reduction in aneurysm size,
reduction in patient morbidity and mortality, reduction in patient
discomfort and recovery periods, a decrease in blood loss and the
need for transfusion and lowering of cost. To make endovascular
repair a viable alternative to surgical repair, durable results must
be achieved.

Patient selection for endovascular repair is critical to
achieving good outcomes. The primary diagnostic study is a
contrast-enhanced spiral or helical CT scan of the entire
abdominal aorta and iliac arteries. Nonionic contrast media of
150 ml are infused via an 18- or 20-gauge IV in an antecubital
vein at 3-4 ml per second. Spiral/helical CT acquisition is done
from the celiac artery to the femoral bifurcations using 3 mm
collimation at a pitch of 2- 1 or 3- 1 . The images are reconstructed
at a 1.5 mm slice thickness.

Also obtained are 2D coronal and sagittal computer-
reconstructed images and 3D maximum-intensity projection and
shaded surface display reconstructions.

Careful measurements are made, and key features required
for the ANCURE Endograft include an infrarenal neck of a
diameter no greater than 26 mm, which is at least 10-15 mm in
length.

Care should be taken to avoid superior necks with
intraluminal thrombus or extensive calcification. For the
bifurcated endograft, the iliac “landing zones” must be less than
14 mm in diameter and at least 20 mm in length. The presence

Fig. 3. Shaded surface display (SSD) reconstruction of
contrast-enhanced spiral CT (posterior view).

Fig. 4. Intraoperative aortogram with the Angioscale
Catheter (lower arrow) shows AAA (upper arrow) and
right common iliac artery aneurysm (middle arrow).

Number 7

January 2001 • 251

of excessive tortuosity and dense
calcification may he relative
contraindications to endograft
placement.

The femoral and iliac access
arteries must be able to accept the
24 French ipsilateral expandable
sheath and a 12 French
contralateral sheath to allow
successful graft delivery.

Before endovascular repair, a
marker catheter arteriogram is
done with the Angioscale
Catheter (Guidant, Menlo Park,

Calif.). This is especially useful
for judging the length of the
endograft to be deployed and
confirming diameter measure-
ments.

Occasionally, preoperative
embolization of large branch
arteries, such as accessory renal,
inferior mesenteric, lumbar or
internal iliac arteries, may be
performed. This may, in some
cases, decrease the occurrence of
retrograde flow of blood into the
excluded aneurysm sac, a complication that is known as
an endoleak.4 As with any surgical procedure, patients are
carefully evaluated for cardiovascular, respiratory and
hematologic risk factors.

Patients for endovascular repair of AAA’s are prepared
similarly to those undergoing open repair, i.e. NPO before
the procedure, bowel prep and prophylactic antibiotics. Al-
though most endovascular repairs are done using general
anesthesia, some endovascular physicians have used
epidural or local anesthesia with conscious sedation.

Endovascular repair with the ANCURE Endograft is
done using bilateral femoral cut-downs and arteriotomies.
A 24 French expandable sheath is placed via the ipsilateral
femoral arteriotomy and a 1 2 French sheath is placed in the
contralateral femoral artery. The ANCURE Endograft is
contained within a 23.5 French delivery catheter and is
placed through the ipsilateral sheath into the infrarenal aorta,
with positioning monitored by intraoperative fluoroscopy
and arteriography. The contralateral limb of the graft is snared
via the contralateral sheath and brought into appropriate
position within the iliac artery. Both proximal and distal
attachments are anchored with stents and hooks, which are
secured in place with balloon dilatation.

The body of the graft is constructed of woven polyester
similar to routine aortic graft material. One unique feature
of the ANCURE Endograft is its bifurcated unibody design
(one piece of fabric), which is constructed with stents at
the proximal and distal attachment zones but is unsupported

throughout the body and limbs
of the graft. This design may
decrease the incidence of late
complications (i.e. endoleak or
limb kinking/occlusion) since
it is flexible and able to
conform to changes in the size
and shape of the aneurysm sac
that are known to occur with
time.5

Case Presentation

A.E. is a 68-year-old man
with no significant past
medical problems, who was
noted to have an AAA on
routine physical examination.
His father had also had a large
AAA that required emergent
repair about 40 years ago. An
ultrasound of the abdomen
confirmed a 4.7 cm infrarenal
AAA, and a subsequent
contrast-enhanced spiral CT
scan delineated the AAA (Fig.
1), as well as a 3 cm right
common iliac artery aneurysm
(Fig. 2). Measurements taken included a 25 mm diameter
infrarenal neck extending about 5 cm in length. To assess
the configuration of the aneurysms and perform length
measurements allowing selection of the appropriate-size
ANCURE Endocraft, 2D and 3D CT reconstructions (Fig.
3 ) were done. Confirmatory measurements were made with
a marker catheter arteriogram.

Because the right common iliac aneurysm was noted
to extend close to the origin of the internal iliac artery,
embolization of the internal iliac artery was performed
using Gianturco coils (Cook Inc.) (Fig. 4). This was done
to allow extension of the ipsilateral graft limb over the
origin of the internal iliac artery to completely exclude
the common iliac aneurysm and prevent an endoleak.

One week following the arteriogram and internal iliac
artery embolization, the patient underwent placement of
an ANCURE Endograft in the operating room at St. Vincent
Infirmary Medical Center. The procedure was done under
general anesthesia using bilateral femoral arteriotomies. A
26 mm diameter, 1 6 cm long ANCURE Endograft was placed
under fluoroscopic guidance.

Completion arteriography in the operating room
showed complete exclusion of both the abdominal aortic
aneurysm and the right common iliac aneurysm without
evidence for endoleak or limb stenosis (Fig. 5).

The patient was able to be ambulatory that evening
and resumed a regular diet. He was discharged the following
morning without complications. A follow-up CT scan at

Fig. 5. Completion of the intraoperative aortogram shows
complete exclusion of the aneurysms with the ANCURE
Endograft.

252 • The Journal

Volume 97

one week showed
thrombosis of the
aneurysm sac around
the endograft with
successful exclusion of
both the AAA (Fig. 6)
and the right common
iliac aneurysm (Fig. 7).

There was no evidence
of an endoleak or other
complication. The
patient was able to
resume his normal
activities within 10
days, including playing
a round of golf.

Discussion

Our patient high-
lights some of the
major advantages of
endovascular repair.

Experience has shown
lower morbidity, less
blood loss, shorter
hospital stays and
recovery time, and a
quicker return to
normal activities with
endovascular repair as
compared to conven-
tional surgical repair.6

Successful exclu-
sion of aneurysms
using endografts is
achieved in a high
percentage of patients,
with Jacobowitz et al.
reporting only 3% of
669 patients under-
going emergent ex-
plantation and surgical conversion and 4% requiring late
elective conversion because of persistent endoleak,
migration or enlargement of the aneurysm.7

These data were collected from patients receiving the
early EVT endograft as well as ANCURE, and improved
success rates are expected with the improved ANCURE
Endograft. In high-risk patients, endovascular repair is also
safe and effective and may be considered the preferred
method of treatment.8 Patient acceptance is very favorable
as post-procedure discomfort is mild and there is such a short
down time for patients with this minimally invasive repair.

At present, the cost of the available devices offsets the
savings generated by shorter hospital stays and reduced
morbidities, making the cost of endovascular repair very

similar to open repair.
It is thought that as
more devices are
approved for clinical
use, prices will de-
crease, making endo-
vascular repair more
cost- effective than
open repair and more
appealing to hospitals’
financial analyses.

Not all patients
with AAA’s are can-
didates for endovas-
cular repair, however,
and careful screening is
required with CT and
arteriography. With the
currently available
endovascular devices,
40-75% of patients may
be amenable to endo-
vascular repair. The
average normal dia-
meter of the abdominal
aorta in women is
approximately 1.8 cm
and, in men, 2.2 cm.
Most physicians con-
sider treatment of an
AAA as it approaches
a diameter of twice nor-
mal. In general, once
an AAA reaches 4.5-
5.0 cm diameter, sur-
gical repair is usually
recommended.

There is debate
among endovascular
physicians whether the
threshold for endovas-
cular repair should be lowered. There are those who believe
that since the endovascular repair of smaller aneurysms is
frequently technically simpler than with larger aneurysms,
and that more patients may be suitable candidates (because
of less expansion to involve the juxtarenal segment of aorta
and less tortuosity and angulation of the aortic neck and
iliac arteries), endovascular repair should be recommended
for patients at an earlier stage.

It has been hypothesized hy some investigators that the
incidence of late complications may be less after
endovascular repair of smaller aneurysms, since there will
be a proportionately smaller change in size and config-
uration of the aneurysm sac. This question is being debated,
and further study will be required before a consensus is

Fig. 7. Lower image from the postoperative CT shows thrombosis of the right
common iliac artery aneurysm (arrow) around the right limb of the Endograft.

Fig. 6. A one-week postoperative CT scan shows thrombosis of the aortic
aneurysm sac (arrow) around the enhanced limbs of the ANCURE Endograft.

Number 7

January 2001 • 253

reached on the appropriate threshold
for endovascular repair.

Complications

The failure of an endograft to
completely exclude an aneurysm from
arterial blood flow is called an
endoleak. This continued blood flow
into the aneurysm sac around the
endograft is best diagnosed by contrast-
enhanced spiral/helical CT. White et
al. developed a classification system for
endoleaks, with Type I referring to
leaks at the prox-
imal or distal
attachment zones
due to incom-
plete seal, Type II
representing flow
to the aneurysm
sac via branch
arteries9, Type III
caused by defects
in the graft ma-
terial or modular
disconnection,
and Type IV being
graft porosity.10

The most
common type of
leak is a Type II
leak, but the sig-
nificance of these
is not clearly un-
derstood. Early
Type II endoleaks
are common and
may occur in up
to 40% of patients following
endovascular repair. 4,9> 10 The majority
of these will resolve spontaneously
without intervention, but most
endovascular physicians feel that
careful follow-up with CT is
important.

There have been reported cases of
aneurysm rupture following endo-
vascular repair, complicated by a
persistent endoleak. If the aneurysm is
seen to be shrinking despite an
endoleak, no intervention is generally
felt to be necessary, but if there is
expansion of the aneurysm, correction
of the endoleak is required.

Type I endoleaks can usually be

resolved by angioplasty and/or stenting
of the attachment zone leak. In Type
II leaks, careful arteriography is
required to identify the inflow and
outflow branch arteries to the
aneurysm sac. Most of these will be
amenable to embolization with
resolution of the endoleak. Type III
leaks are less common but may require
additional graft segments or
explantation of the endograft and
conventional surgical repair. Type IV
leaks are seen with some of the graft
materials but have not been reported
with the ANCURE Endograft. When
they occur, Type IV leaks are almost
always transient, requiring no
intervention.

Other serious complications of
endovascular repair are uncommon but
include arterial trauma with rupture,
dissection or occlusion, wound
infection; blue toe syndrome from
distal embolization; myocardial
infarction; and acute renal failure. As
with traditional surgical grafts, limb
stenosis or occlusion may occur, which
could require thrombolysis, angio-
plasty, stenting or surgical revision.
Pyrexia following endograft placement
is fairly common but is thought to be
of no significance.

Conclusions

Endovascular repair is an exciting
new minimally invasive treatment
option for some patients with AAA’s.
Careful screening with contrast-
enhanced CT and arteriography is
necessary to identify patients who are
appropriate candidates. Endovascular
repair compares favorably with open
repair in the protection from rupture
but is associated with less morbidity,
shorter hospital stays and recovery
time, and less pain. Post-implantation
follow-up CT scans are required to
assess for endoleak, and some patients
may require further intervention.

Dr. Knox is a physician with
Radiology Associates PA in Little Rock.
Dr. Meadors is a physician with
Cardiovascular Surgeons PA in Little
Rock.

Bibliography

1. Zarins CK, Harris J. Operative
repair for aortic aneurysms: The
gold standard. J Endovasc Surg

1997;4:232-241.

2. Zarins CK, et al: AneuRx stent
graft versus open surgical repair of
abdominal aortic aneurysms:
Multicenter prospective clinical
trial. J Vase Surg 1999; 29:292-308.

3. Parodi JC, Palmaz JC, Barone HD.
Transfemoral intraluminal graft
implantation for abdominal aortic
aneurysms. Ann Vase Surg 1991;
5:491-499.

4. White GH, Yu W, May J et al:
Endoleak as a complication of
endoluminal grafting of abdominal
aortic aneurysms: Classification,
incidence, diagnosis, and
management. J Endovasc Surg
1997;4:152-168.

5. Harris P, et al: Longitudinal
aneurysm shrinkage following
endovascular aortic aneurysm
repair. J Endovasc Surg 1999;
6:11-16.

6. May J, et al: Concurrent
comparison of endoluminal versus
open repair in the treatment of
abdominal aortic aneurysms:
Analysis of 303 patients by life
table method. J Vase Surg 1998;
27:213-221.

7. Jacobowitz GR, Lee AM, and Riles
TS, for the EVT Investigators.
Immediate and late explantation of
endovascular aortic grafts: The
Endovascular Technologies
experience. J Vase Surg 1999;
29:309-316.

8. Chuter TAM, et al: Endovascular
aneurysm repair in high-risk pa-
tients. J Vase Surg 2000; 31:122-133.

9. White GH, May J, Waugh RL, et
al: Type I and Type II endoleak: A
more useful classification for
reporting results of endoluminal
AAA repair. (Letter) J Endovasc
Surg 1998;5:189-191.

10. White GH, et al: Type III and Type
IV endoleak: toward a complete
definition of blood flow in the sac
after endoluminal AAA repair. J
Endovasc Surg 1998; 5:305-309.

If the aneurysm
is seen to be
shrinking
despite an
endoleak, no
intervention is
generally felt to
be necessary,
but if there is
expansion of
the aneurysm,
correction of
the endoleak is
required.

254 • The Journal

Volume 97

PEOPLE+EVENTS

Legal Guides Put to Use

AMS President Dr. Gerald Stolz and Dr. James
Kyser recently delivered 525 copies of the AMS’
Physician’s Legal Guide, Second Edition to residents at
the University of Arkansas for Medical Sciences.

The gift was a joint effort of the AMS and the
Medical Education Foundation for Arkansas, the
medical Society’s educational foundation. Dr. Jeanne
Heard, associate dean for graduate medical education,
submitted a grant request to MEFFA last spring
expressing the need for residents — especially those
in their last year of training — to be aware of laws
and regulations affecting the practice of medicine.

AMS’ new legal guides are presented to U AMS residents. Left to right, Dr. James Kyser, Dr.
Joseph Keuter, Dr. Iuirry Markham, Dr. Owen Kelly and Dr. Gerald Stolz, AMS president.

HONORED

Physician, Entrepreneur
Receives Distinguished
Service Award

Dr. Paul I. Wills of Fort
Smith received the Distin-
guished Service Award from
the American Academy of
Otolaryngology — Head and
Neck Surgery on Sept. 24-

The award was pre-
sented to Dr. Wills during the
opening ceremony of the
Academy of Foundation
Annual Meeting/Oto Expo
in Washington, D.C., in
recognition of his many years
of service to the Academy. Dr.
Wills served as secretary and
chair of the board and
governors and is a member of
several committees. He also
has served on the editorial
board of the American
Journal of Otolaryngology.

Dr. Wills was honored as
Businessman of the Year in
1999 by the National
Republican Congressional
Committee. It was one of six
awards distributed across the
country to the top business
leaders who have been
instrumental in helping to
reform the Internal Rev-
enue Service, pass the
Financial Freedom Act of
1999 and maintain a Repub-
lican majority in Congress.

Dr. Wills is in private
practice at the Otolaryn-
gology — Head and Neck
Surgery Division of Cooper
Clinic in Fort Smith and has
established Wills Labs, a
nutritional supplement com-
pany based in Hewitt, Texas.

He is a graduate of

Baylor College of Medicine
in Houston. He completed
residencies in Arizona and
Houston and a two-year term
with the U.S. Air Force.

Physicians Receive
Awards from AMA

Each month the Amer-
ican Medical Association
presents the Physician’s Re-
cognition Award to those
who have completed accep-
table programs of continuing
education.

AMA recipients for
June include Drs. Lori Beth
Bacon, Anton L. Duke and
Brian M. Kubacak, all of
Little Rock; Drs. Elisa M.
Payne and Timothy L.

Spradlin, both of Fort
Smith; Dr. Jody Warren
Peebles of North Little
Rock; Dr. James R. Arnold
of Jonesboro; Dr. Donald L.
Cohagan of Bentonville; Dr.
Joseph A. Cook of Conway;
Dr. John S. Elkins of
Arkadelphia; Dr. Michael
C. Hendren of Russellville;
Dr. Jose S. Padilla of Har-
rison; Dr. Harry D. Starnes
of Clinton; Dr. Joe M.
Tullis of Mountain Home;
Dr. Richard D. Tutt of
Springdale; and Dr. Bruce
A. White of Malvern.

AMA recipients for J uly
include Drs. James D.
Billie, Gunnar H. Gibson
and William Q. Sturner, all

of Little Rock; Drs. John C.
Dobbs and Jimmie J. Magie,
both of Conway; Drs. Wil-
liam W. Galloway of Russell-
ville; Dr. John D. Ginger of
Fayetteville; and Dr. Morton
C. Wilson of Fort Smith.

AMA recipients for
August include Dr. Russell
B. Allison of Russellville,
Dr. Charles W. Logan of
Little Rock and Dr. Jane
Scott of Sherwood.

AMA recipients for
September include Dr.
Robert C. Power of Little
Rock, Dr. Ronald E. Re-
vard of Harrison, Dr. Rhe-
eta M. Stecker of Hot
Springs and Dr. Robert C.
Thompson of Van Buren.B

Number 7

January 2001 • 255

New Members

Tammy G. Albrecht, MD

Specialty: FP

207 Carter St.

Berryville, AR 72616
(870) 423-6661

Fareeda Ann Al-Refai, MD

Specialty: R

P.O. Box 1269
Fort Smith, AR 72902
(501) 494-0500

Clarence J. Arendall, MD

Specialty: Resident-FP

2907 E. Joyce Blvd.
Fayetteville, AR 72703
(501) 521-8260

Michelle S. Banning, MD

Specialty: FP

P.O. Box 220
Danville, AR 72833
(501)495-7300

Bing X. Behrens, MD

Specialty: N
3 1 1 E. Matthews
Jonesboro, AR 72401
(870) 935-4150

Michael F. Berry, MD

Specialty: R

302 N. 8th St., #3
Rogers, AR 72756
(501) 621-6033

Terry Mac Brown, DO

Specialty: FP

P.O. Box 699
Judsonia, AR 72081
(501) 729-3114

Shannon H.

Brownfield, MD

Specialty: Resident-FP

2907 E. Joyce Blvd.
Fayetteville, AR 72703
(501) 521-8260

Aris Calhoun, MD

Specialty: FP

1500 McLain St.

Newport, AR 72112
(870) 523-9337

Stephen M.

Chatelain, MD

Specialty: OBG

9601 Lile Drive, # 850
Little Rock, AR 72205
(501) 217-8467

Vera Y. Collins, MD

Specialty: Resident-FP

612 S. 12th St.

Fort Smith, AR 71901
(501) 785-2431

James B. Cotner, MD

Specialty: FP

25 Professional Park Drive
Clarksville, AR 72830
(870) 862-2489

Robert M. Cowherd, MD

Specialty: Resident-FP

4010 Mulberry St.

Pine Bluff, AR 71603
(870) 541-6010

Paul E. Daidone, MD

Specialty: IM

200 S. Moose St.

Morrilton, AR 72110
(501) 354-4637

Bruce A. Darrow, MD

Specialty: OB

2010 Chestnut, #B
Van Buren, AR 72956
(501)410-1966

Richard K. Davis Jr., MD

Specialty: Resident-FP

460 W. Oak St.

El Dorado, AR 71730
(870) 862-2489

Orrin J. Davis, MD

Specialty: Resident-PD

800 Marshall St.

Little Rock, AR 72202
(501) 320-1875

Justin D. Dawson, MD

Specialty: Resident-FP

223 E. Jackson
Jonesboro, AR 72401
(870) 972-0063

Alberto Dominguez-
Ventura, MD

Specialty: Resident-GS

4301 W. Markham St., #520
Little Rock, AR 72205
(501) 405-1952

Anton L. Duke, MD

Specialty: PD

500 S. University Ave., #200
Little Rock, AR 72205
(501) 661-0308

Delilah L. Easom, MD

Specialty: Resident-IM

4301 W. Markham St.

Little Rock, AR 72204
(501) 686-5162

Frank D. Edwards, MD

Specialty: FP
101 Hospital Drive
Magnolia, AR 71753
(870) 235-3000

Bobby T. Ensminger, MD

Specialty: Resident-FP

612 S. 12th St.

Fort Smith, AR 72901
(501) 785-2431

Etiya M. Farooq, MD

Specialty: Resident-FP

4301 W. Markham St.

Little Rock, AR 72205
(501) 686-6560

Ronnie M. Fenton, MD

Specialty: R

500 S. University Ave., #108
Little Rock, AR 72205
(501) 664-3914

Christine M. Finck, MD

Specialty: Resident-GS

800 Marshall St.

Little Rock, AR 72203
(501)320-1446

Regina P. Foley, MD

Specialty: Resident-FP

4010 S. Mulberry St.

Pine Bluff, AR 71603
(870) 541-6010

Sean M. Foley, MD

Specialty: Resident-PM

4301 W. Markham St.

Little Rock, AR 72205
(501) 686-5444 ■

LETTER Continued from page 232
before on clinical income for survival.
Likewise, most of the residents are going
into private practice and can profit
greatly from your experience in that
field. The rewards in academics must be
measured by standards other than total
financial gain, however. It is true that
incomes are much lower, but I contend
that the rewards are much higher. Not
only are the residents often appreciative
of your hard-won practical insights, but
there is a chance to change the actual
practice of medicine for the better
through areas of either basic or clinical
research. It is immensely satisfying to see
some paper on which I spent a year’s
effort referenced in the literature, or hear
a resident mention its message. That
ranks right up there with doing a clinical

case of importance and difficulty in the
special procedures room and caring for
that patient and family, previously my
greatest professional pleasure. Research
and teaching may actually have more
positive impact on the big picture of
health care than anything else I can do.
It can be very good indeed.

I see others who are fed up with the
greed, pettiness, and red tape that now
constitutes so much of medical care,
turn away from a true calling to an early
retirement of no substance. We were all
trained to do things of substance. We
are good at it. We need it. We should
not turn to the life of the dilettante.
Instead, I would suggest an alternative
which, though far from perfect and
occasionally burdened with pointless
hassles, may be a good fit for some

individuals. Give academics a try. The
need for faculty is acute in many areas.
This can take advantage of your lifetime
of work and training, allow you to give
back to the community in ways you
never anticipated, and, most of all, may
provide that satisfaction which all of us
need in our lives. Do it for the future of
medicine. Do it for yourself. ■

Sincerely,

William C. Culp, MD

Assistant Professor

Chief, Section of Vascular and

Interventional Radiology

Department of Radiology

University of Nebraska Medical Center

256 ® The journal

Volume 97

Mountain Harbor Resort

Mountain Harbor Resort is Lake Ouachita’s premier resort
community.

It is nestled in the quiet coves and forested shorelines of Lake
Ouachita, the state’s largest man-made lake. This family-owned
resort offers warm hospitality, fine accommodations, a full-service
marina and a wide array of recreational opportunities.

Guests may spend the night in an airy lodge with rooms
that open onto a big lawn overlooking the lake, poolside
cabanas, cottages with lake views and hot tubs or beautifully
appointed condominiums. All cottages and condos offer fully
equipped kitchens, cable television, telephones and native
stone fireplaces.

During off-season, from the day after Labor Day through the
end of February, prices range from $55 per night for a lodge room
without kitchenette to $225 per night for a three-bedroom, three-
bath unit. In-season prices are $79.95-$295 per night. A three-
night minimum is required on all holiday weekends. For
reservations, call (870) 867-1200.

Nearby Hot Springs touts a variety of restaurants, or guests
may dine at the casual resort restaurant, known for its catfish,
steaks, burgers, homemade desserts and Southern-style breakfasts.
Work off those biscuits and gravy by nature watching, playing

water sports, hiking or horseback riding.

Deer, black bears, wild turkeys and other wildlife live in the
Ouachita National Forest, and the lake is a wintering home for
eagles. In fact, one of the resort’s most popular events is Eagle
Extravaganza, an eagle-watching event scheduled for the last week
of February.

Lake Ouachita is a popular destination for swimmers, scuba
divers, water skiers, sailors and fishermen, and the resort’s full-
service marina offers pontoon, ski and fishing boats for rent.

Horse lovers should call Mountain Harbor Riding Stables,
(870) 867-3022 for a guided trail ride.

The Ouachita Mountains boast 480 miles of nature trails,
including the 192-mile Ouachita National Recreation Trail.
Detailed trail maps are available from the Mt. Ida Area Chamber
of Commerce, (870) 867-2723.

Finally, the resort is a perfect base for a weekend getaway to
Hot Springs’ Oaklawn Park, which offers thoroughbred racing from
February-April.

The resort lies on the southern shore of Lake Ouachita. It is a
30-minute scenic drive from Hot Springs National Park and just 1 2
miles east of rustic Mt. Ida. Visit www.mountainharborresort.com
for information and driving directions. ■

Number 7

January 2001 • 257

ADVERTISERS INDEX

AMS Benefits Inc Inside back cover

Arkansas Financial Group Inc., The 234

Arkansas Foundation for Medical Care Inside front cover

Asti, William Henry, AIA 249

Central Flying Service 243

EmCare 244

Farmers Insurance Group 243

Fiser Hummer 234

Health Data Services, LLC 248

Jefferson Regional Medical Center 258

Little Rock Medical Associates 249

Maggio Law Firm 238

Medical Practice Consultants Inc 242

PhyAmerica Physician Services Inc 240

Regions Bank 242

Smith Capital Management 248

Snell Prosthetic &. Orthotic Laboratory Back cover

St. Vincent Health System 249

State Volunteer Mutual Insurance Co 233

University of Arkansas for Medical Sciences 244

Special Publications

Editorial Art Director

Publisher
Brigette Williams

Irene Forbes

Advertising Art Director

Special Publications

Matt Stewart

Editor- in -Chief
Natalie Gardner

Advertising Coordinator
Kristen Heldenbrand

Assistant Editor
Christy L. Smith

Marketing Assistant
M itzi Tiffee

Copy Editor
Donna Schratz

Database Administrator
Andrea Martin

Sales Manager
Stephanie Hopkins

Advertising Assistant
Greg Duszota

Account Executives
Jason Carson

▲ ARKANSAS BUSINESS

Liz Earlywine

PUBLISHING GROUP

Director of Design

Chairman &. Chief Executive Officer

and Circulation

Olivia Farrell

Virgeen Healey

President and Publisher
Jeff Hankins

Director of Marketing
Allison Picked

Executive Vice President
Sheila Palmer

Production and

Circulation Coordinator
Jeremy Henderson

www.abpg.com

Primary Care
Practice Opportunity

Clinic-based primary care
opportunity for Internal
Medicine for Cleveland
County, Arkansas, a health
professional shortage area.
Available to applicants with
authorization to work. Send
CV, with salary require-
ments and references to
Jefferson Regional Medical
Center, 1515 West 42nd Av-
enue, Pine Bluff, AR 71603,
ATTN: Sharon Theriot.

|| Doctor of the Day y

The Arkansas Medical Society
needs YOU to participate in the
1A1 Doctor of the Day program, during
this year’s Legislative Session.

☆☆☆

To get involved, call Laura Harrison
at the AMS office, (501) 224-8967
or (800) 542-1058.

258 • The Journal

Volume 97

ui'niu:

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Journal

OF THE ARKANSAS MEDICAL SOCIETY

Winner of the ASAE Excellence in Communications Award

CONTENTS

FEATURES

270 Family Ties

For some people, medicine is a family affair. Meet two families
that have made taking care of people a tradition. The Young
family of Texarkana touts nine doctors, while the Jacks brothers
of Pine Bluff are looking to groom more doctors in their family.

274 Meet Our Members: Dwight M. Williams, MD

Dr. Dwight M. Williams credits his brother’s childhood accident
and his daughter’s death for giving him the drive to keep the
families of his native Paragould healthy .

Dr. Mitchell Young, with wife Donna,
raised 1 0 children, and eight of their
sons became doctors .

— page 270

283 The Langston Collection

A plaque and book collection at the University of Arkansas for
Medical Sciences honors the lives of Dr. William C. Langston
and his son, Bill. The legacy of medicine in the Langston
family runs deeper than any plaque can convey, though.

DEPARTMENTS

267 Commentary

Samuel E. Landrum, MD

269 What We’ve Done
For You Lately
277 Loss Prevention
280 Cardiology Report
282 State Health Watch
287 People + Events

289 Arkansas Retreats

290 Index to Advertisers

Journal

Medicine runs deep in the Langston
family too. A tribute at LAMS
honors Dr. William C. Langston and
his son, Bill.

— page 283

On the cover: The Young family:
upper right, Dr. Mitchell and Donna
Young ; center wedding picture , the
Young brothers; lower left, Drs. Chris,
Michael and David Young; lower right,
Drs . Matthew and Tom Young.

Cover design: Irene Forbes

Number 8

February 2001 • 265

Developing
Your Estate
Plan?

Keep These Tips In Mind.

Contributed by:

Micheal D. Munson

Senior Vice President— Investments

A.G. Edwards

1501 N. University, Suite 100
(501) 664-9135

You’ve spent years growing
your wealth and planning
your estate, so it is just
good sense to plan to protect your
assets and pass them on to your
beneficiaries according to your
wishes. When you’re ready to sit
down with your financial profes-
sional and develop an estate plan,
keep these tips in mind.

Write a will. If you do not have a
will when you die, the law of your
state may then determine what
happens to your estate, your as-
sets and any minor children. In
addition, the state process, usu-
ally governed by probate court, is
often slow, sometimes expensive
and open to the public.

Fund a living trust. Follow
through as you set up a living
trust. Until you transfer owner-
ship of property or assets to it,
the trust is not worth any more
to you or your beneficiaries than
the paper its printed on. Unfor-
tunately, many revocable living
trusts are set up but remain un-
funded.

Re-Title ‘JROWS" property.

Joint-Tenancy- With-Right of Sur-
vivorship titling of assets may re-
sult in estate planning headaches.
Although probate is avoided at the
first joint owner’s death, it is not
avoided at the death of the survi-
vor, thus only delaying estate
taxes. Re-titling assets to a credit

shelter trust can help avoid pro-
bate and provide estate taxes sav-
ings.

Use both spouses’ applicable ex-
clusion amount. Leaving all prop-
erty and assets to a spouse may
avoid estate taxes at the death of
the first spouse, but this approach
wastes the gift and estate tax credit
of the “first-to-die.” A credit shelter
trust can maximize each spouse’s
credit, thus sheltering more assets
from estate tax liabilities.

Re-title ownership of life insur-
ance policies. Most life insurance
policies are owned by the insured,
causing the policy’s face amount
to be included in that person’s es-
tate at his or her death. Policy
owners may consider giving poli-
cies directly to the beneficiary or
transferring the policies to an ir-
revocable insurance trust. Either
strategy could help reduce taxes.
Choose an appropriate executor.
Naming an inexperienced family
member as executor could compli-
cate the demanding task of settling
your estate. This is especially true
at a difficult and emotional time
following a death. Look into the
benefits of naming a professional
organization to follow through with
the duties of an executor.
Organize your paperwork and
files. If you do not provide your ex-
ecutors and beneficiaries with all
the paperwork or files pertaining

to your property, assets and wishes,
improper distribution and manage-
ment of your estate may result.
Update your estate plan. Updat-
ing your estate plan from time to
time is important so that it is imple-
mented exactly according to your
wishes. You will want to update
your estate plan when there are
changes in your family (births, mar-
riage, divorces, deaths, etc.), or
when the value of your estate sig-
nificantly increases or decreases,
when tax laws change, if you move
to another state or if your business
or career changes.

When you are ready to begin your
estate planning strategies, talk to
your financial advisor. Be sure to
consult your tax and legal advisors
as well before making any tax-re-
lated or legally related investment
decisions.

If you would like to learn more,
please write to us in care of Arkansas
Business Publishing Group, 201 E.
Markham St., PO Box 3686, Little
Rock, AR 72203, to the attention of
Stephanie Hopkins.

This article does not constitute tax or legal advice.
Consult your tax or legal advisors before making
any tax-related or Legally related Investment de-
cisions. This article Is published for general in-
formational purposes and is not an offer or so-
licitation to sell or buy any securities or
commodities. Any particular Investment should
be analyzed before on Its terms and risks as they
relate to your circumstances and objectives.

COMMENTARY

COMMUNICATIONS COORDINATOR

Judy Hicks

EXECUTIVE VICE PRESIDENT

Kenneth LaMastus, CAE

ASSISTANT EXECUTIVE VICE PRESIDENT

David Wroten

EDITORIAL BOARD

Sue Chambers, MD
Joseph M. Beck, II, MD
Lee Abel, MD
Samuel Landrum, MD
Jerry Kendall, MD
William Ackerman, MD

Pediatrics
Oncology
Internal Medicine
Surgery
Family Practice
Anesthesiology

EDITOR EMERITUS

Alfred Kahn Jr., MD

ARKANSAS MEDICAL SOCIETY
2000-2001 OFFICERS

Gerald A. Stolz, Jr., MD, Russellville
President

Joe Stallings, MD, Jonesboro
President-elect

Paul A. Wallick, MD, Monticello
Vice President

Lloyd G. Langston, MD, Pine Bluff
Immediate Past President

Carlton L. Chambers, III, MD, Harrison/Little Rock
Secretary

Dwight M. Williams, MD, Paragould
Treasurer

Anna Redman, MD, Pine Bluff
Speaker, House of Delegates

Kevin Beavers, MD, Russellville
Vice Speaker, House of Delegates

Joseph M. Beck, II, MD, Little Rock
Chairman of the Council

Established 1890. Owned and edited by the Ar-
kansas Medical Society and published under the di-
rection of the Council.

Advertising Information: Contact Stephanie
Hopkins, P.O. Box 3686, Little Rock, AR 72203;
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The Journal of the Arkansas Medical Society
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Periodicals postage is paid at Little Rock, Arkansas,
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Articles and advertisements published in The Jour-
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content and advertisements.

IS THAT SO?

Samuel E. Landrum, MD, FACS

So much of what we learned in early medical education 30 or 40 years
ago has been shown either to be unnecessary or to be so opposite
current practices that it is humbling.

One of the duties of the night resident was to insert Levin tubes
early in the morning in all who were scheduled to have their gall
bladder removed that day. Long intestinal tubes were passed per os prior
to elective intestinal resection, and colon-resection patients were in the
hospital for four days pre-op for a thorough prep.

Some of these practices were continued in the early years of my
private practice because they had been stressed so much for patient
safety. Fortunately, brave surgeons or patients defied the standard
practice arid led to the discovery that the tubes did not add to safer
operations with fewer complications. Improvements in anesthetic
techniques and agents have probably contributed in a major way to this
change.

Reflection on those and other changes in medical dicta have made
me wonder what is right and true. Dwelling on these reflections can he
almost depressing.

Recently, two papers reporting experience with CT scans and
ultrasonography in suspected cases of appendicitis were presented at a
meeting of surgeons.

The first review of 776 cases seen at the University of California at
Davis showed that the long-observed symptoms and signs of appendicitis
were more predictive of the correct diagnosis and that CT and US
should be used rarely and selectively. Obtaining these studies delayed
getting to the correct diagnosis and operation.

The second study, reported from Scott and White Memorial
Hospital in Texas, found that CT scans of the RLQ and pelvis
substantially improved the accuracy of diagnosis, especially in females in
their teens and early reproductive years.

These studies probably will he in the Archives of Surgery next spring
if one is interested in the details of these reports. This is a current area
of disagreement among various radiologists, surgeons, primary-care, and
emergency physicians.

At the same meeting, there was a panel of four surgeons on groin
hernia repairs, and there was considerable divergence of preferences for
various techniques. Use of mesh, which approach, or whether
laparoscopic exposure is good were not points of universal agreement.

These are simply two recent exposures dealing with common surgical
procedures that I enjoyed. Yet when listening to the speakers with
obvious, different convictions, I had to remember, “Is that so?” ■

Dr. Samuel E. Landrum is a retired general surgeon from Fort Smith. Dr.
Landrum is a member of the editorial board for The Journal of the Arkansas
Medical Society.

Number 8

February 2001 • 267

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268 • The Journal

Volume 97

INFORMATION FOR AUTHORS

WHAT WE’VE DONE FOR YOU LATELY

The Journal of the Arkansas Medical Society
reserves the right to edit any material submitted.
The publishers accept no responsibility for
opinions expressed by the contributors.

MANUSCRIPT STYLE

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REPRINTS

Prompt-Payment Rule
Moves Forward

By David Wroten

There is no question that one of the most important issues for Arkansas physicians
has been prompt payment of insurance claims. For nearly two years, the leadership
and staff of the Arkansas Medical Society have placed this issue at the top of their
agenda. The hard work may finally be ready to pay off.

Jan. 1 , 2001, was the implementation date of the Arkansas Insurance Department’s
new prompt-payment rule, known as Rule 43. The Arkansas Medical Society and the
Arkansas Hospital Association negotiated with the insurance industry for the better
part of last year to craft a regulation that is, it is hoped, fair and enforceable. The
Insurance Department adopted the proposal with only minor modifications.

A big victory for physicians and other health care providers is a new requirement
that the department investigate complaints filed by providers. Previously, the
department only recognized complaints filed by patients. The new provision allows
providers to file consumer complaints where there is a reasonable basis to believe that the
health carrier has exhibited a practice of not paying that providers’ claims according to the rule.

In other words, a physician’s office cannot file a complaint over just one claim.
The bottom line is that if a physician is having claim problems with a specific carrier,
the Insurance Department will, for the first time, investigate the complaint. This is a
major step forward.

Other key provisions of the rule;

• Clean claims must be paid or denied in 30 days if submitted electronically, or in
45 days if submitted by other means.

• For claims that require additional information, the carrier has 30 days from
receipt of the claims to request the infonnation. After receipt of the information, the
claims must be paid or denied within 30 days.

• Carriers that fail to process clean claims within 60 days must pay the provider a
penalty of 12% per annum. The same penalty applies to other claims not processed
within 45 days of receipt of the additional infonnation. The penalty must be paid
automatically and without any action by the provider.

The rule establishes a standard for timeliness, requiring 85% of all claims to be
processed within 30 days and 98% within 45 days. If the carriers’ claim-filing practices
fall below a certain minimum standard, regulatory intervention is triggered. The
minimum standard is 60% of claims processed within 30 days and 85% processed
within 45 days.

So what is a clean claiml The AMS reviewed clean claim definitions from across
the country without finding a single, clear, unambiguous definition. The language
that was finally agreed to provides that a clean claim is one submitted on an HCFA
1500 or other standard form with all required fields completed in accordance with the
health carriers’ published claim- filing requirements.

There are the usual provisions stating what is not a clean claim, such as a claim
that requires additional information. However, another important provision requires
the carrier to provide you with a copy of its claim-filing requirements upon request.
These must be published, and complaints can be filed with the Insurance Department
if they are unreasonable. The commissioner can order the carrier to alter or discontinue
requirements that are unreasonable or unduly burdensome.

This new regulation is not a silver bullet and will not stop some carriers from
bending or trying to break the rules. However, for the first time, there is a regulatory
arena that physicians can turn to for settling these disputes.

This has been another example of your AMS at work for you. ■

Number 8

February 2001 • 269

The Young brothers celebrate at Dr. David Youngs wedding. From left to right , Matthew, Chris, John, Holly, David, Patrick, Tom, Mark and Michael.

Family Ties

Medicine Runs Deep in Some Arkansas Families

By Natalie Gardner and Mark Friedman

Editor’s Note: Medicine is often a family affair. Those who
practice it for 30 or 40 years tend to pass the tradition on to
bright sons and daughters or nieces and nephews. Children see
how their elders helped others, and many are ready to do the
same once they are grown. My dad followed in his uncles’ footsteps
and became an ophthalmologist. He looked up to those men and
knew that if they found the field fulfilling, he would, too. He
learned from them that medicine is a good way to help others
while making a good living for him and his family.

That’s exactly what the eight sons of Dr. Mitchell Young of
Texarkana discovered. They admired their dad in his career and
were eager to carry on the family tradition. And once the first
few sons made the leap, it wasn’t hard for the others to follow.

The same goes for Drs. Dennis and David Jacks of Pine Bluff.
Although their father wasn’t a physician, the entire family was
active in the community. Medicine was a natural step for all
these brothers — their way of giving back to society.

D r. Mitchell Youngs oldest son announced he wanted to
follow in his dads footsteps and become a doctor.

Then his brothers jumped on the bandwagon.

In the end, all eight of Youngs sons became doctors. Five
are orthopedic surgeons, two are emergency-medicine
doctors, and the youngest son is a veterinarian. One of Dr.
Youngs two daughters went into the health profession,
becoming a registered nurse. The other daughter is a teacher
for the U.S. Department of Defense in Stuttgart, Germany.

Of course, the Young brothers are use to the typical
questions: Was your dad the inspiration for you all? Do you
guys talk about medicine when you get together?

But to families like the Youngs, medicine is “in the genes.”

Dr. Young, 72, knew he wanted to go into medicine when
he was 6, after being hit by a car, suffering a broken leg, in
his hometown of Texarkana, Texas, where he lives now.

“I just thought it was a way to help people,” he said. “I
thought it was what I should do.”

270 * The Journal

Volume 97

Even Dr. Youngs wife has the medical drive. She was a
nurse before having 10 children in 14 years.

Dr. Youngs parents, both accountants, taught him the
value of hard work. While in school, Dr. Young peddled
papers and worked at a Boy Scout camp while keeping an
eye on becoming a doctor.

After graduating from the University of Arkansas, he
went to the University of Arkansas Medical School in Little
Rock, graduating in 1953.

While he was doing his residency at St. Louis City
Hospital, he met his future wife, Donna, and fell in love. They
were married in 1955. After three additional years of training
at Southwestern Medical Center/Parkland Hospital in Dallas,
Dr. Young opened his general surgery practice in his
hometown, where he practiced for 41 years until his recent
retirement.

The Value of Hard Work

Sitting at his dining room table in his two-story white
brick house, Dr. Young said he and his wife instilled a good
work ethic, discipline and faith in all of their children.

Watching the children grow up, Dr. Young noticed that
they were determined and worked hard at what they did.
They also excelled at sports and had good hand-eye
coordination, a plus in the operating room.

“I hoped they would go into medicine, but I never pushed
medicine on them,” he said. He just wanted them to be happy
in the profession they chose.

Dr. Young and his wife gave their children chores to do
around the house and on their 70-acre farm.

One summer, the boys spent a week building a barbed-
wire fence around the ranch.

“It taught them hard work and responsibilities and
working together,” Dr. Young said. “It [also] taught them
perseverance.”

Another valuable life lesson for Dr. Young and his children
came from the Boy Scouts of America.

“I started out in Boy Scouts when 1 was 12, and it has
meant so much in my life,” Dr. Young
said. “I think all young men should
be members of Boy Scouts, and girls
should be members of Girl
Scouts. I really feel strongly
about that.”

Scouting teaches young-
sters to depend on them-
selves, to survive in the
outdoors and to become
community leaders, Dr.

Young said.

“But mostly you
learn to be a citizen of
this country and do the
best at whatever you
do,” he said.

In the Young
household, before

the teen-agers were allowed to drive, they had to earn their
Eagle Scout award.

All the sons accomplished that goal, giving the family the
honor, for a time at least, of having the most Eagle Scouts.
The girls also had to earn the Girl Scouts’ equivalent of the
Eagle Scout award before they could drive.

“I think scouting and strong religious life ... were the keys
[to the childrens success],” Dr. Young said.

Dr. John Young, 34, an orthopedics and sports medicine
specialist in Shreveport, La., said scouting was a major force
in his life and one of the reasons he decided to go into medicine.

“Medicine seemed like a natural step after Boy Scouts,” he
said. “Many of the things we learned in Boy Scouts apply to
medicine, such as taking care of people.”

Outside of scouting, the Young family spent a lot of time
together at the childrens various sporting events, namely
football and tennis.

Dr. Mitchell Young, a former Razorback football player,
also instilled his love of sports in his sons.

“You have to learn to be tough, and you learn that in
athletics,” he said.

Dr. Chris Young, 35, an orthopedic surgeon in Hot
Springs, said the brothers’ involvement in sports was one of
the main reasons five of them chose orthopedics as their
specialty.

“I had both my shoulders operated on during high school
because of football," he said. “Orthopedics tends to be full of
the good old boys and jocks. It was really competitive, and
you had to be at the top of your class to get into orthopedics.
For me, it was something to shoot for.”

Becoming Doctors

The oldest sibling. Dr. Michael Young, 44, a partner with
Chris in Hot Springs, was the first to choose medicine as a
career and orthopedics as a specialty.

The second oldest son, Mark, 43, an orthopedics specialist
in Mount Pleasant, Texas, and third-oldest son, Dr. Tom Young,
an orthopedics specialist in Texarkana, soon decided to head

to medical school, too. Pretty
soon, all the boys were in
medical school.

At one time, four —
John, Chris, David and
Matthew — were
studying at the
University of
Arkansas for
Medical Sci-
ences.

A Guide to the Young Family

With so many successful children, it’s hard to keep up with
the Young family, but here’s a look at Dr. Mitchell and
Donna Young’s children and where they are.

Dr. Michael Young, 44, of Hot Springs, orthopedics
Dr. Mark Young, 43, Mount Pleasant, Texas, orthopedics
Lesa Young, 42, Benton, registered nurse
Dr. Thomas Young, 41, Texarkana, Texas, orthopedics
Mary Young, 39, Stuttgart, Germany, teacher
Dr. David Young, 37, Searcy, emergency medicine
Dr. Chris Young, 35, Hot Springs, orthopedics
Dr. John Young, 34, Shreveport, La., orthopedics
Dr. Matthew Young, 32, Texarkana, Texas, emergency medicine
Dr. Patrick Young, 31, Washington, Okla., veterinary medicine

Number 8

February 2001 • 271

John and Chris were in the same medical school class, while
older brother David was just a year ahead of them. Younger
brother Matthew was two years behind them.

“Chris and I helped each other through medical school,
which was a big help,” Dr. John Young said.

Going into orthopedics wasn’t a hard decision for John,
who was eager to follow in his dads and older brothers’ footsteps.
“I’ve always looked up to my older brothers.”

David, 37, a physician in Searcy, and Matthew, 32, a
physician in Texarkana, are the two brothers who went the route
of emergency medicine. The youngest sibling, Dr. Patrick Young,
3 1 , is a veterinanan in Washington, Okla. , working exclusively
on horses.

“I wanted to be a cowboy and a doctor, so this was a good
choice for me,” Dr. Patrick Young said.

Patrick performs surgeries and rehabilitation on race and
show horses. His daily routine is not far off from his brothers’ in
orthopedics.

“Horses are athletes,” he said. “What I do is a lot like doing
human orthopedics. We can do a lot for these horses to improve
their performance.”

“We’ll all get together to go duck hunting and spend the
night in one of those huge outfitter’s tents with a stove in it,”
Chris said. “Mark will cook his famous cobbler, and we’ll make
a huge breakfast the next morning.”

When they get together, medicine doesn’t always rule the
conversation, Chris said.

“We talk about medicine some, about interesting things
that we’ve seen,” Chris said. “But we’re really down-to-earth,
regular guys. We talk about other things, like everyone’s family
or who we’ve seen lately.”

One thing all the brothers agree on is the kudos their
parents should get for raising 10 successful children who are
all giving back to society.

“Dad set such a wonderful example for us,” John said. “He
was happy, and we could tell. All the credit goes to our mom
and dad.”

“Dad was the best example I could have had,” Chris said.
“I learned that 1 could help people and make a good living at
it, too. I really am extremely happy being a physician. Being a
servant is a wonderful way to make a living.”

Following in Dad’s Footsteps

Dr. Mark Young said he thinks so many of his siblings
went into medicine because his dad set a good example. Dr.
Mitchell Young would tell his children that they were blessed
to live in the United States, where they could get an education,
and that they owed it to society to give something back, Mark
said.

Mark remembers seeing people come to his house for
medical help. People would also go up to his dad and tell him
he saved their lives. He also remembers seeing his father cry
after losing patients.

Matthew, the second youngest sibling, said he couldn’t
put his finger on why his family had the medicine bug. But he
said the help-others attitude of his parents played a big role.

“It’s a profession where you can help your fellow man and
feel like you accomplished something at the end of the day,”
Matthew said.

Another reason the brothers chose medicine is that the
family is so close.

The brothers refer to one another as best friends and look
forward to getting together at the family’s cabin outside Hot
Springs.

“Holidays are a big time for our family,” Dr. John Young
said. “And Razorback games are, too. We all end up at the
cabin, put the Razorbacks on the radio, barbecue and just
have a great time. We’re all avid outdoors people, so we go
to the cabin and mountain-bike, canoe and hike.”

But the family passion is duck hunting. Chris said duck
hunting was one reason he and John stayed at home and
went to a junior college for two years before heading to the
University of Arkansas at Fayetteville.

Brothers David and Dennis Jacks of Pine Bluff enjoy their *

working partnership. H;

Photo: Kirk Jordan V

The Jacks Brothers

Drs. David and Dennis Jacks have a commitment to
improving the health of their hometown residents — and
they are doing it together.

Since 1989, the brothers have
been partners, along with Dr.

David Lupo, at South Arkansas
Urology in Pine Bluff.

“We’re Pine Bluff boys,” Dr.

David Jacks said, smiling. The
sons of prominent Pine
Bluff residents Ray and
Jane Jacks, the bro-
thers speak
proudly of
the heri-
tage their
parents

272 • The Journal

gave them. Jane Jacks worked for
years in Pine Bluff’s paper
production industry, while Ray
Jacks spent 50 years with the Pine
Bluff Fire Department, 27 as fire
chief. Ray Jacks also worked on
his off days at Western Union and
was active in the Democratic
Party.

“People tried to get him to
run for mayor,” Dr. David Jacks
said, but he was not interested
in professional politics.

The brothers agreed that their mother’s strong work ethic
and their father’s emphasis on education put them on the
path toward medicine. And serving as teen-age orderlies at
Jefferson Regional Medical Center sent them further on their
way.

Dr. David Jacks, 50, returned to Pine Bluff in 1981
immediately following medical school and his residency. In
1986, he recruited Dr. David Lupo as a partner. Three years
later, his brother left the military to join them.

One of the biggest challenges the brothers face in their
practice is that they have the same last name. Patients and
insurance representatives often get confused.

“I’m trying to get him to change his name,” Dr. Dennis
Jacks, 48, said, joking.

But the brothers seem to enjoy
their partnership. Because of their
two-year age difference, Dr.
Dennis Jacks never really felt
much sibling competition. “We
didn’t really run around together.
David had older friends and I had
younger friends,” he said.

Their lives have had strong
parallels, though. In addition to
attending the same medical
school, both are divorced fathers
who enjoy hunting and the outdoors. Both of their sons
also followed in their fathers’ footsteps by becoming
orderlies at Jefferson Regional Medical Center. David has
two sons, Bradley, 17, and Blake, 13, while Dennis has three
children, William, 21, Ashley, 19, and Megan, 15.

When asked if any of their children were headed to
medical school, both men were hopeful.

“My 13-year-old wants his name out here in front of
this building. He wants to, not because I want him to. He’s
going to make it on his own. My older son, Bradley, wants
to be a neurosurgeon one day, an oral surgeon the next day
and nothing the next day,” David said, laughing.

Only time will tell if the tradition will continue. ■

Susan Van Dusen contributed to this story.

One of the biggest challenges the
brothers face in their practice is that
they have the same last name.
Patients and insurance
representatives often get confused.

| | Please check if you are

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Number 8

February 2001 • 273

M eetJDur_ Members

Dwight M. Williams, MD

By Christy L. Smith

Dr. Dwight M. Williams believes in a strong family unit. A
childhood accident involving his brother and the death of his
oldest daughter eight years ago reinforced that idea, he said.

“I can’t think of anything good about the deterioration of
the family structure,” he said. “I believe that if you don’t have a
strong family unit, you will not succeed.”

The 49-year-old family practice physician at Paragould
Doctors’ Clinic was one of six children bom to blue-collar parents.
A childhood accident in which his younger brother, Wallace,
lost two fingers piqued Dr. Williams’ interest in medicine, he
said.

“I was 8, and he was 5. We were playing with an old lawn
mower, and I ended up amputating a couple of his fingers,” Dr.
Williams said.

The family’s physician, Dr. Jacob Williams (no relation) of
Paragould, was able to reattach one of the fingers. The family
practice physician’s ability to handle such an injury inspired Dr.
Williams, he said.

Dr. Williams, a native of Paragould, graduated with a de-
gree in zoology from Arkansas State University in Jonesboro in
1975. He enrolled at the University of Arkansas for Medical
Sciences in Little Rock in 1976. After graduation, Dr. Williams
completed a fam-
ily practice
residency
and in-
ternship
at the
Arkan-
sas Area
Health
Education
Center in
Jonesboro.

He has been in

Dwight Hiiiliams, M.D.

private practice since 1983. He has been one of four partners at
Paragould Doctors’ Clinic since 1986.

Dr. Williams said it was always his intent to go back to
Paragould to practice even though he had heard that small-town
physicians were often “inundated by requests from family and
friends” to treat their ailments. But Dr. Williams hasn’t had to
grapple with that problem because he adheres to a personal rule
against treating close relatives, he said.

“1 treat some, but not close, relatives. It would be hard to
make life and death decisions for my wife and children,” Dr.
Williams said.

Dr. Williams met his wife, Judy, a former registered nurse,
while the two were attending ASU. By working at Doctors’
Hospital in Little Rock, Judy Williams helped put her husband
through medical school. She left nursing about 20 years ago to
raise the couple’s three children.

The Williamses’ oldest daughter was killed eight years ago in
an automobile accident. Dr. Williams’ mother-in-law was driving
the car, which hydroplaned during a thunderstomr, he said. The
accident had a lasting effect on the Williams family.

“It was a profound experience, losing a daughter. It was a
stress on the family, but it was something we were stronger for
afterward,” he said.

Family closeness helped the Williamses through that difficult
period, he said.

“My wife was very supportive, even though she had to be
hurting. And having two other children gave us the will to get
through it. I can’t imagine losing an only child and not having
the family support to fall back on,” he said.

The Williamses’ other children are Traci, a 20-year-old
Hendrix College student who recently completed a semester at
Oxford University in England, and J arrod, 1 8, a high school senior.
Both children are considering careers in medicine, Dr. Williams
said, but neither has settled on a distinct course yet.

But there’s no doubt in Dr. Williams’ mind that medicine is
his calling, he said. His only hope is that he has conveyed that
sentiment to his patients.

“I hope I have always given my patients
something they could rely on [and the idea that] I
am not in it for just the business of medicine,”
he said. “I have certainly gained a lot by being
in family medicine. I learn every day, and I
just can’t imagine doing anything else.”

Dr. Dwight Williams , AMS
treasurer, says his family has
learned a lot from the death of
his oldest daughter.

Photo: Kirk Jordan

Volume 97

Dr. Williams said that 40% of his
patients are elderly but that he particularly
enjoys the pediatric aspect of the
profession.

When he was in medical school, he
said, “I was within a day of going to a
pediatric residency but changed my mind.
1 lost a real close patient in pediatrics and
wasn’t sure at the time that I could handle
that. I thought I would be better suited
doing family practice.”

Dr. Williams’ day begins at 7 a.m. with
rounds at Arkansas Methodist Hospital
in Paragould. He usually sees four to eight
patients there and then starts work at the
clinic at 9 a.m., attending to the “typical
family medicine” problems of about 50
patients by the end of the day, he said.

Although he maintains a busy
schedule, Dr. Williams tries to spend his
one-hour lunch break every day with his
wife because “that’s the one meal we can
almost guarantee ourselves together,” he
said.

Dr. Williams’ day usually ends at 6
p.m., although he shares call duties with
seven other doctors.

“I don’t know how people did it 20 years
ago, taking their own call 24/7,” he said,
adding that in the old days he probably
would have chosen a different specialty to
escape the demands on his time.

Dr. Williams said he had seen many
changes in the practice of medicine
during the past 17 years, including
managed care and patient tolerance.

With so many changes, Dr. Williams
said he has relied heavily on the
Arkansas Medical Society.

“Most doctors aren’t aware of all the
ins and outs of how medicine interacts
with other entities, such as insurance
companies and legislators,” he said. “It
takes several years to learn how all that
works, but the Society helps its
members keep tabs on it all.”

When he began practicing in 1983,
managed care “was not an issue. Doctors
would see anybody who walked in,” he
said. But managed care arose in Paragould
in the late 1980s “when some of the
private industries developed a primary-
care network,” he said.

As a result, it is now harder for a
physician to go into solo practice in
Paragould, Dr. Williams said.

“He can get in [the network], but it
may take 12 months to get through all

the paperwork and jump through all the
hoops,” he said. Most area doctors enter
solo practice “after they’ve been
established for a while.”

“The Society has been there
looking out for our interests when
managed care looks at cutting costs,”
he said. “When they start to cut, they
first look at hospital and doctor budgets.
I understand their problem, hut they are
looking for a quick fix, and cutting
doctors’ fees hurts everybody, especially
the patients. The Society is a huge
advocate for patients.”

Another change is that patients and
“everyone associated with medical care”
want answers to health problems within
hours, Dr. Williams said. “People aren’t
as patient, and that puts us all in a
hurried pace.”

One thing Dr. Williams is not in a
hurry to do is retire. He said he would
practice full time for another decade and
then scale back his practice, possibly
embarking on overseas mission trips and
serving locum tenens, or as a fill-in
physician for those who need to take time
off.

“I don’t think I would be happy not
working,” he said.

Dr. Williams has already embarked on
one mission trip. For seven days in
December, he helped mn a clinic in an
underserved area of Romania.

“My partner had been on a couple of
mission trips before, and he said they
needed to sign up another doctor,” he said.
“They wanted a doctor, a plumber and a
preacher, and I knew I could handle at least
one of those.”

Dr. Williams has been a member of
the Arkansas Medical Society since 1983.
He served as first district councilor from
1990-98 and has completed two years as
the society’s treasurer.

Dr. Williams was appointed to the
Arkansas State Board of Health by Gov.
Jim Guy Tucker in 1993 and was
reappointed by Gov. Mike Huckabee in
1998.

In his free time, Dr. Williams enjoys
gardening and is a licensed pilot. But his
favorite pastime is scuba diving in the
Caribbean with his children. “That was
an interest they had, and, at 12 or 13 years
old, they needed somebody to be their
buddy. It’s a good family thing to do
together,” he said. ■

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Number 8

February 2001 • 275

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2 76 • The Journal

Volume 97

LOSS PREVENTION

A Horrible

J. Kelley Avery, MD

System for Everybody

Case Report

The family physician had been this patient’s
doctor for about 10 years, during which time he
had been treated for a few minor illnesses and
injuries. This present episode of care began with
the patient complaining of low back pain, to which
he added, somewhat as an afterthought, that he
was having some bright bleeding when he had a
bowel movement.

He first noticed the blood in the commode
mixed with the stool, but not on the toilet paper.
The physician did a brief examination focused on
the chief complaint of backache and rectal
bleeding.

On rectal examination, the stool on the exam-
ining glove was negative for blood hy guaiac test.

The patient was reassured and given some
instructions relative to his low back pain, and he
was told to conduct three consecutive examinations
of the stool at home using the Hemoccult
technique. The record does not indicate whether
or not he complied with those instructions.

Within the month, the patient reported that
he was still having some rectal bleeding, but there
was no documented examination, and, from the
record, the presumption was that he was advised
by office staff to make an appointment and return
about a week later.

On this return visit, the history was that the
patient was having some bright bleeding with each
stool but that he had not noted any tarry stools.
This bleeding had been noticed more often during
the last two weeks. There was no family history of
colon cancer.

The examination revealed some comedones
around the anal opening. At the five o’clock posi-
tion on the anus, the physician noted a small fissure
from which he believed the blood had come, though
he found no blood on anoscopic examination.

The prostate was said to be enlarged, boggy,
and slightly tender. The patient was given
prescriptions for a sulfa derivative for his prostatitis,
anal suppositories, and a bulk laxative. Wann soaks
were advised as well.

Two weeks later, the patient’s wife called to
report that her husband was still having rectal

bleeding but that if asked, he would deny it. Indeed,
when asked by an associate of the family physician’s,
the patient did deny the bleeding.

The wife again called and requested that her
husband’s doctor inquire about the bleeding. The
patient was seen a few days later for an upper
respiratory infection, and, at that visit, the
physician recommended complete studies
including sigmoidoscopic examination. The
patient refused the referral.

Ten months after the initial complaint of
rectal bleeding, the patient was seen by his doctor
for complaints of abdominal cramping, some low
back pain, and continued rectal bleeding.

The examination of the abdomen was negative
for tenderness or masses, and bowel sounds were
nonnal. The patient denied having constipation.

Anoscopic examination was repeated, with the
same finding of a shallow fissure. Again a rectal
examination was done, and this time the material
on the examining glove was positive for blood. Both
doctor and patient were increasingly concerned
about the possibility of disease higher up in the
bowel. A barium enema and a sigmoidoscopic
examination were scheduled.

Examination revealed a flat lesion, vascular in
appearance, which on biopsy was found to he a
moderately well-differentiated adenocarcinoma of
the rectum. The patient was referred to a colorectal
surgeon who scheduled surgery, hoping to perform
a primary anastomosis, but this proved to be
impossible, making an abdomino-perineal resection
with permanent colostomy the procedure of choice.
The tissue specimen was examined in its entirety,
and five lymph nodes were found to be positive for
the cancer.

About one year after the surgery, a chest X-ray
showed lesions in both the right upper and the left
lower lobes of the lungs. These lesions progressed
in size and the patient was advised that he was
incurably ill. He was told that further treatment
would prolong his life hut that it would adversely
affect the quality of his remaining months. He
subsequently developed some mental changes,
stumbling about and showing disorientation,
which proved to he caused hy brain metastases.

Number 8

February 2001 • 277

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A lawsuit was filed, charging the
family physician with failure to diagnose
and treat colon cancer in a timely manner.
The case was tried, initially resulting in a
jury verdict in favor of the physician.
However, on appeal, the case was remanded
to the trial court.

The trial had been a severe emotional
strain on the family of the plaintiff and on
the physician. Nobody wanted to repeat
that experience. A settlement was reached
for a relatively small amount.

Loss Prevention Comments

Early in the course of the investigation
of this lawsuit, a dispute developed between
the patient and the physician as to whether
the Hemoccult tests on the stool done early
in the course of the patient’s disease were
reported to the physician.

The wife, the patient being disoriented
and mentally incompetent at the time,
insisted that they had informed the
physician’s office that the tests had all been
positive. The physician insisted that the
tests had not been reported and that
consequently, he assumed the tests had
been negative. There was no documen-
tation either way.

It has to be pointed out that during the
trial, the patient presented a pitiable
picture, with his difficulty walking and his
obvious mental and emotional deteri-
oration. The trial was devastating for all
concerned. On appeal, nobody wanted to
repeat the experience, but a retrial was
scheduled.

The plaintiffs’ experts insisted that the
delay of a year in conducting the definitive
tests determined the bad result. The defense
experts contended that no one could tell
the time of onset of the cancer and that no
one could tell whether the delay had
anything to do with the outcome. However,
with some testimony taking the physician
out of an acceptable standard of care, and
with the sympathetic picture of the plaintiff
and his family, the settlement was accepted.

How should this family physician have
conducted his care of this patient? On the
first encounter with the complaint of rectal
bleeding, the physician documented that
he ordered three consecutive stool
examinations, to be carried out by the
patient himself. There was no
documented report on these tests, though
the plaintiffs contended that the

278 • The Journal

Volume 97

physician’s office had been called and
informed that the tests had been positive.

In the absence of a report on these
tests, the physician assumed that the tests
had been negative or that the patient had
not done the tests as prescribed. On the
next encounter, the patient again
complained of rectal bleeding, and,
thinking that the Hemoccult tests had been
negative, one physician did an anoscopic
examination, found the anal fissure, and
assumed it was the site of the bleeding.

It was treated, and it was eight months
before the complaint was brought to the
doctor’s attention again. At this time, the
attending physician advised the complete
study, but it was refused by the patient. It
was only after two months that the patient
finally cooperated with the recom-
mendation, the diagnosis was made, and
definitive surgery was done.

The question remains whether or not
the physician made logical clinical
decisions on the basis of the information
he had. The ending of the first trial in a
defendant’s verdict indicated that the jury
believed that the attending physician had
made clinical decisions within an
acceptable standard of care.

The absence of documentation of the
events in the ongoing visits was perhaps a
fatal error that would have been further
exploited at retrial.

Since the emotional trauma for
everybody involved in the first trial was an
experience nobody wanted to repeat, the
physician requested a settlement, if it could
be reached for a reasonable amount. This
was done, and the agony ended. Nobody
was satisfied! Nobody ever is in medical
malpractice lawsuits!

This case illustrates the vagaries of the
medical malpractice legal system. It also
illustrates the necessity of careful,
complete documentation of physician-
patient encounters during the course of
investigating and managing a patient’s
complaint. ■

Reprinted from a December 1 999 issue of
Tennessee Medicine. The Case of the Month
is taken from actual Tennessee closed claims.
An attempt is made to fictionalize the material
in order to make it less easy to identify . If you
recognize your own case , please be assured that
it is presented solely for the purpose of
emphasizing the issues presented.

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Number 8

February 2001 • 279

CARDIOLOGY

Tobacco Cessation

AUTHOR: Lee Davis, MD — EDITOR: Eugene S. Smith, III, MD

Few interventions are as cost-
effective as tobacco cessation, but fre-
quently, practitioners become discour-
aged by the high relapse rate. The
appropriate addition of pharmaco-
therapy can improve the success rate.
This article reinforces an established
approach to identifying and assisting our
patients addicted to tobacco products
and outlines the pharmacologic
interventions available to assist them.

There are 46 million tobacco users in
the United States, and 435,000 die each
year as a result of their use.1 Tobacco users
are at increased risk of developing
cardiovascular disease, cancer, hyper-
tension, stroke, respiratory disease and pre-
term labor.

As a consequence of chronic tobacco
use, an annual $50 billion is spent directly
on medical cost, in addition to the $47
billion spent indirectly.2

Despite adequate education and
serious health consequences, most
tobacco users find smoking cessation
impossible. Seventy percent of tobacco
smokers present to their primary-care
physicians each year. It’s in this setting
that the likelihood of smoking cessation
can be improved. Physicians today have
numerous treatment options for smoking
cessation, ranging from drugs to
behavioral interventions.

Smoking Cessation

Spontaneous smoking cessation
occurs in 1-2% of tobacco users and
increases to 3-5% with physician

encouragement.1 Usually, 4-5 attempts
are needed to achieve smoking
cessation.4 With drug intervention,
smoking cessation rates double compared
with placebo.13

Five drugs have been approved by
the FDA for smoking cessation. Nicotine
gum was introduced in 1984 and was
followed by the nicotine patch in 1994,
nicotine spray in 1996, bupropion in
1996 and the nicotine inhaler in 1998.

Pharmacotherapy

Studies have shown that nicotine
gum increases cessation rates at six
months by a factor of 1 .6-2.8, compared
with placebo.6 It is available in doses of
2mg and 4 mg. Dosing recommen-
dations should be based on the level of
tobacco usage.

Dosing of 4 mg is suggested for
individuals with a daily usage of more than
24 cigarettes, and 2 mg for less than 24
cigarettes. Nicotine gum can safely be used
for six months and is now available only
as an over-the-counter prescription.

The highest level of compliance of
all the smoking cessation drugs has been
shown to be with the nicotine patch. It is
available over the counter and as a
prescription.

Dosing ranges from 7-21 mg per 24-
hour dosing and 15 mg per 16 hours.
Usually, the initial patch is used for four
weeks, with the wearer tapering off with
use of a lower-dose patch over the next
four weeks.

The nicotine patch improves

cessation rates, especially in the black and
Hispanic population, according to studies.
That should be taken into consideration
when treating this population of tobacco
users.7, 8 Cessation rates at six months for
the nicotine patch increase by a factor of
1.6-2. 8 compared with placebo.6

Local irritation of the throat and
mouth is a common adverse effect that
many patients report when using the
nicotine inhaler. The nicotine inhaler
increases cessation rates by a factor of 1 .8-
3.5 at six months compared with placebo.6

The nicotine inhaler is provided in
cartridges, with a recommended dosing of
6-16 cartridges per day. It can be used
safely for up to six months and only by
prescription. The nicotine inhaler mimics
regular cigarette use and may also provide
an added benefit to those individuals
whose tobacco use is a habit as well as an
addiction.

The nicotine spray delivers nicotine
more rapidly than any other nicotine
replacement therapy,9 producing peak
serum levels in 10 minutes.10 This property
makes nicotine spray the drug of choice
when the goal is to reduce cravings or
withdrawal symptoms acutely.

One-two doses of nicotine spray are
suggested each hour. Tobacco users should
not exceed 40 doses in 24 hours.

N icotine spray doubles cessation rates,
compared with placebo. There are some
reports of nose and eye irritation with
frequent dosing.

Bupropion is the only oral non-
nicotine replacement therapy approved by

280 • The Journal

Volume 97

the FDA. The recommended dosage is
150 mg for three days, followed by 150
mg twice a day for 7- 1 2 weeks. Bupropion
increases cessation rates by a factor of 1 .5-
1 .7 at six months compared with placebo.6

The major side effects of bupropion
are insomnia, dry mouth, headaches, and
tremors. One of the main contrain-
dications for bupropion is the presence of
seizure disorders. But it can be safely
combined with any of the nicotine
replacement therapies.

Numerous studies have been
conducted on various combinations of
smoking-cessation drugs. Combinations
include nicotine patch-nicotine gum,
nicotine patch-nasal spray, and trans-
dermal nicotine patch-bupropion. All
showed increase cessation rates compared
with monotherapy.11, 12, 14

All therapies should be in con-
junction with intensive behavioral
interventions. Patients should be provided
adjuvant therapies such as counseling,
educational materials, social support
groups, and smoking cessation clinics. All
of the above stated cessation rates were
in conjunction with extensive adjuvant
therapies.

Withdrawal Syndrome

Nicotine is the addicting component
of tobacco. With smoking cessation,
tobacco users develop withdrawal
symptoms within 24 hours because of the
physiological deficit of nicotine. Tobacco
withdrawal syndrome includes depression,
irritability, hostility, impatience, head-
aches, restlessness, anxiety, and cravings.

Relapse peaks within the first seven
days and is most commonly caused by
withdrawal syndrome.4

The Physician’s Role

The U.S. Public Health Service
published specific guidelines to identify
and treat these patients. Key guideline
recommendations are known as the 5 As:
ask, advise, assess, assist and arrange.

The first step is to ask and thus
identify the tobacco user. Measures should
be taken to address tobacco use in each
patient presenting to your practice. Once
a tobacco user is identified, he or she
should be advised to discontinue use.

Advisement is then followed hy
assessment. Tobacco users’ level of

motivation to discontinue tobacco use
should be gauged.

Assist all patients with achieving
tobacco cessation and set a quit date. If
the patient has no desire to discontinue
tobacco use, patient education should be
initiated. The deleterious effects of
continued tobacco use should be
explained.

Once a decision to continue or
discontinue tobacco usage is made, a
follow-up is arranged. The follow-up can
be performed by letter, return visit or
telephone.

Conclusion

Smoking cessation is cost-effective,
and, depending on the stage of disease,
the risk of smoker- induced disease can he
improved. All the present FDA-approved
smoking cessation drugs are equally
efficacious when used correctly.6 The
disadvantages and advantages of smoking-
cessation drugs should be used to determine
the adequate drug for a tobacco user.
Combination therapies should be provided
for those tobacco users failing mono-
therapy. Drug therapies combined with
aggressive behavioral interventions
improve cessation rates overall.5

Smoking cessation can decrease the
risk for lung disease, coronary artery
disease, hypertension, and stroke.4 There
is no level of safe tobacco use. Every
attempt should be made to achieve
smoking cessation. ■

Drs. Davis and Smith are from the
division of cardiology, DAMS Medical
Center, and the John L. McClellan
Memorial Veterans Hospital.

References

1 . US Department of Health and Human
Services. Healthy People 2000.
Washington DC: US Government
Printing Office; 1991. DHHS
publication (PHS)91-50212.

2. Centers for Disease Control and
Prevention. Medical expenditure
attributable to cigarette smoking-United
States, 1993. MMWR M orb Mortal
Why Rep. 1994; 43:925-930.

3. Fiscella K, Franks P. Cost effectiveness
of the transdennal nicotine patch as an
adjunct to physicians’ counseling.
JAMA. 1996.275:1247-1251.

4. US Department of Health and Human
Services. The Health Benefits of

Smoking Cessation. Washington, DC:
Public Health Service, Center for
Chronic Disease Prevention and Health
Promotion, Office of Smoking and
Health; DHHS publication (CDC)90-
8416.

5. Shiffman S, Pinney JM, Gitchell J,
Burton SL, Lara EA. Public health
benefit of over-the-counter nicotine
medications. Tob Control. 1997.
275:1270-1280.

6. Hughes JR. Combining behavioral
therapy and pharmacotherapy for
smoking cessation: an update. In: Onken
LS, Blaine JD, Boren JJ, eds: Integrating
Behavioral Therapies With Medication
in the Treatment for Drug Dependence:
NIDA Research Monograph. Wash-
ington, DC: US Government Printing
Office, 1995. 92-109. Monograph 150.

7. Ahluwalia JS, McNagny SE, Clark WS.
Smoking cessation among inner-city
African Americans using the nicotine
patch. J Gen Intern Med. 1998. 13:1-8.

8. Leischow SJ, Hill A, Cook G. The
effects of transdermal nicotine for the
treatment for Hispanic smokers, Am J
Health Behav. 1996. 20:304-311.

9. Schneider NG, Lunell E, Olmstead RE,
Fagerstrom KO. Clinical pharmacol-
ininetics of nasal nicotine delivery: a
review and comparison to other nicotine
systems. Clinical Pharmacokinet. 1996.
31:65-80.

10. Gourlay SG, BenowitzNL. Arterio-
venous differences in plasma con-
centration of nicotine and catecho-
lamines and related cardiovascular
effects after smoking, nicotine spray, and
intravenous nicotine. Clin Phannacol
Ther. 1997. 62:453-463.

1 1. Fagerstrom KO. Combined use of
nicotine replacement products. Health
Values. 1994. 18:15-20.

12. Blondal T, Gudmundson LJ, Olafsdottir
I, Gustavsson G, Westin A. Nicotine
nasal spray with nicotine patch for
smoking cessation: randomized trial with
six-year follow-up. BMJ. 1999. 318:285-
288

13. Hughes JR, Golstein MG, Hurt RD,
Shiffman S. Recent advances in the
pharmacotherapy of smoking. JAMA.
281(l)/:72-6. 1999 Jan 6.

14-Jomby DE, Leischow SJ, Nides MA, et
al. A controlled trial of sustained-release
bupropion, a nicotine patch, or both for
smoking cessation. N EngJ Medicine.
1999. 340:340:685-691.

Number 8

February 2001 • 281

Reported Cases of Selected Diseases in Arkansas

Profile for October 2000

The three-month delay in the disease profile for a given month is designed to minimize any changes
that may occur due to the effects of late reporting. The numbers in the table below reflect the actual
disease onset date, if known, rather than the date the disease was reported.

Disease Name

Total Reported

Cases YTD 2000

Cases YTD 1999

Cases YTD 1998

Cases 1999

Cases 1998

Campylobacteriosis

176

142

159

165

179

Giardiasis

149

129

142

153

168

Salmonellosis

573

593

555

698

616

Shigellosis

163

194

211

Hepatitis A

103

Hepatitis B

103

100

115

Hepatitis C

Meningococcal Infections

Viral/Aseptic Meningitis

Ehrlichiosis

Lyme Disease

Rocky Mountain Spotted Fever

Tularemia

Measles

Mumps

Chlamydia

5,137

5,220

3,201

5,937

4,127

Gonorrhea

3,093

2,825

3,281

3,268

3,962

Syphilis

177

181

267

213

294

Pertussis

Tuberculosis

169

141

122

181

171

For a complete list of reportable diseases in Arkansas, call the Arkansas Department of Health, division of epidemiology, at (501) 661-2893 during normal
business hours.

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2 82 • The Journal

Volume 97

SPECIAL ARTICLE

The Langston Collection

Richard B. Clark, MD

Fig. 1 : Memorial plaque in the library at the University of Arkansas for Medical Sciences.

If one wanders through the library at the University of Arkan-
sas for Medical Sciences on West Markham Street, one will
find, on a wall on the first floor, a plaque bearing the likeness of
two individuals: William C. Langston Sr. (1890-1977), and
William C. Langston Jr. (1919-1943). A memorial book
collection is mentioned (Fig. 1). Who were these people? What
relation do they have with the College of Medicine? Why is
this collection of books dedicated to them?

William Cleaver Langston Sr. was bom Jan. 3, 1890, in
Newberry County, S.C., the son of a Baptist minister. He
graduated from Furman University in 1911 and enrolled in
medical school at Wake Forest College.1 Illness forced him to
drop out, and he assumed the direction of a one-teacher school
at Nixonville, S.C., where he taught all eight grades.

In 1912, he became the principal of a three-teacher school
in the mountain region of North Carolina. From 1914 to 1916,
Langston taught physics and biology at the Brewton-Parker
Institute in Georgia and received a fellowship in biology at

Middlebury College in Vennont, where he later served as a faculty
member.

It is said that during his time as a student, he would sometimes
sign up for a class, and if there was no one to teach it, he would
teach it himself.2

He married Blanche Peacock of Vidalia, Ga., in 1917.
Langston served as a first lieutenant in World War I in the 322nd
Infantry in the Vosges Mountains and Meuse- Argonne campaigns
in France.

When he returned to the United States, he resumed teaching
in Georgia and attended the University of Chicago during the
summers.

The Langstons had lour children: William C. Langston Jr.;
Mary Beth Langston (bom in 1920); Franklin Langston ( 1926-
1994); and Robert H. Langston (bom in 1931 ). In 192 1 , Langston
entered the University of Alabama, alternating teaching and
attending classes.

In 1926, he went to the State University of Iowa as a teacher/

Number 8

February 2001 • 283

Fig. 2: >• William C. Langston,
1890-1977. The plaque was
dedicated “to the memory ofW. C.
Langston, MD, who was close
enough to God to be truly human. As
Professor, Chairman of the Amtomy
Department, Acting Dean and
Professor Emeritus in his 3 1 years at
the University of Arkansas Medical
Center, he related to others with
Christian creativity in such a way as
to enrich their lives and to help them
become truly better people . To his
continuous influence for good , this
collection is now dedicated by those
who called him husband, father,
teacher, and friend."

f :

1 ^ m

'**?*.* ..

-< Fig. 3: William “Bill” C. Langston Jr. 1919-1943. The
plaque was dedicated “to the memory of Bill Langston who,
though having full knowledge of impending death, possessed
a secret of living which so revealed him to God, his fellow
man, and the world reality about him as to enable him to
live the last year of his life purposefully, cheerfully, and
wholly without complaint. This collection of books is
affectionately dedicated by his classmates and fellow students
of the University of Arkansas School of Medicine."

student and, after eight years of part-time school, was awarded
his medical degree.

He remained at Iowa for another year before coming to
Arkansas in 1930. While in Arkansas, he conducted research
with Dr. Paul Day on Vitamin M (folic acid). Dr. Langston
became head of the Anatomy Department in 1941 and was acting
dean of the school from 1948-50.

He was asked to assume the position of permanent dean hut
preferred his role as chairman of anatomy.3,4

This writer found Dr. Langston to he a dedicated teacher
with a sense of humor. One day, while musing on the teaching
of anatomy, he pointed out that although very small, some
structures become very important when they malfunction —
for example, the Canal of Schlemm. He was an excellent,
enthusiastic and somewhat bombastic teacher, continually
drawing multidimensional sketches on the blackboard with
different colors of chalk while lecturing at a rapid pace.5

We students called him “Silver Bill,” but never to his face.
It was only recently that I learned that his preferred nickname
was “Clea.”

Dr. Langston and his family developed a fondness for the
Buffalo River in north Arkansas, and, nearly every summer, they
rented a cabin at Pmitt, on the banks of the Buffalo, subsisting
on fish caught in the river and on chickens and produce
purchased from local farmers. These experiences strongly
influenced his children.

Dr. Langston retired in 19571 (Fig. 2). He continued to work
part time in the department and died in 1977. He was buried in

Roselawn Cemetery in Little Rock. His many years of
teaching Sunday school honored the values of his
father.5

William C. Langston Jr. was bom in 1919 in Vidalia,
Ga. He moved to Little Rock with his family in 1930
and attended Little Rock High School. He attended
the State University of Iowa for three years (1937-40)
and applied for admission to the University of Arkansas
School of Medicine (the School of Medicine became
the College of Medicine in 1975 )3 (Fig. 3). He was
accepted and entered the freshman class in the fall of
1940.

Bill’s progress was satisfactory, but, after a time, he
began to suffer from headaches and then developed
seizures. A brain tumor was suspected, and he traveled
to the Mayo Clinic, in Rochester, Minn., for a second
opinion. The diagnosis was confirmed, and he returned
to Little Rock for surgery, as a young, energetic neuro-
surgeon had arrived in Little Rock.2

This was Dr. Robert Watson, the first
neurosurgeon in Arkansas. Surgery was
performed at University Hospital (which
was then at 12 th and McAlmont). The
diagnosis was astrocytoma, and the surgery
was not successful.

Langston lingered for some time
postoperatively but never regained
consciousness. He died on Nov. 22, 1943,
and was buried in Roselawn Cemetery.

One can imagine the devastation that
overwhelmed the Langston family at Bill’s death.6 He was in his
junior year in medical school. His nickname, “Bill,” appears on
his tombstone. He was a remarkable person, especially during
the tenninal months of his illness. He was an avid reader and a
committed Christian. It was decided that a suitable memorial
for the young Langston would be a collection of books, as both
he and his parents loved learning.

A trust fund was begun and the collection started, to honor
“one who had died while learning the art of Aesculapius.” The
idea was to purchase and keep together books not directly about
medicine, but related to general subjects, such as philosophy and
travel, particularly religion and medicine.

The scope of the Langston Book Collection was defined as
“spiritual in connotation, relating to the study and practice of
medicine — including morality, compassion and the humanness
in the Judeo-Christian philosophy — with a view to broadening
the sciences in service to his fellow man, and his relationship to
God.”

A small alcove was eventually developed where students
could sit and read for enjoyment. When the elder Langston died
in 1977, the present plaque was installed, with both pictures on
it (Fig. 1).

Robert H. Langston was born in 1931 in Little Rock and
attended Little Rock High School, graduating in 1949. He
attended the University of Arkansas at Fayetteville and was
admitted to medical school after three years of premedical study.
He graduated with a medical degree in 1956.

Robert Langston recalls that his father treated him as he did

284 ® The Journal

Volume 97

the other students.2 He married Frances
Simpson in 1953. Langston interned at
Baptist Hospital in Little Rock and then
went into the Army, being stationed at
Fort Chaffee and at the Pine Bluff Arsenal.

In 1960, he entered family practice in
Harrison with Dr. Albert Hammon (with
whom he had preceptored). Dr. Langston
had a busy practice
in Harrison until
he retired in 1996.
He is active in the
Baptist Church,
North Arkansas
Community Col-
lege and the Ar-
kansas Medical
Society (Fig. 4).
Robert and Frances
Langston had
three children:
William Robert (bom in 1956), James
David (bom in 1958) and Thomas Albert
(bom in 1962).

James Langston attended the Uni-
versity of Arkansas at Fayetteville and
graduated from the College of Medicine
in 1988. He completed a residency in
general surgery in

Fig. 4

Robert Langston, M D

1993 at UAMS
and has an active
practice of surgery
in Harrison with
Dr. Tom Bell1 (Fig.

5). He married
Pamela Thompson
in 1986 and they
have two children:

Jacob (born in
1990) and Jillian Fig- 5

(bom in 1 992 ) . j ames Langston , MD

Dr. Thomas Langston joined his
father’s practice in 1990. He attended
the University of Arkansas at Fayet-
teville and graduated from the College
of Medicine in 1987. His residency in
family practice was
at Washington Re-
gional Medical
Center in Fayet-
teville.8 He married
Cindy Lowe in
1983 and they have
three children: Ni-
cholas (born in
1988), Rebekah
(bom in 1991) and
Thomas Langston, MD Maggie (born in

Fig. 6

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Number 8

February 2001 • 285

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1995). He practices medicine at the Family
Doctors Clinic in Harrison, the facility his
father built (Fig. 6).

The Langston Book Collection is no
longer kept together at the library. Some
years ago, the books were distributed
throughout the library collection, according
to their classification, to make them more
accessible and to promote their use.
Although they are not now kept together
as a collection, a memorial book plate
identifies each of the books “In memory of
Bill Langston and Dr. W.C. Langston.”
There is still a fund for purchase of books for
the Langston Collection.

The Langston name is well known and
respected in Arkansas. Thus the term
‘Tangston Collection” applies both to the
collection of books in the UAMS Library
and to this medical family, which has
produced three generations of caring,
dedicated physicians. Their story should be
an inspiration to current and future
physicians.

Will there be a fourth generation?
The Langston great-grandchildren are
too young at this writing to make a com-
mitment, but it remains a possibility. ■

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Dr. Clark is a professor emeritus in the

departments of anesthesiology and obstetrics/

gynecology at the University of Arkansas for

Medical Sciences.

References

1. Obituary: Dr. W.C. Langston, Sr.,
Arkansas Gazette, April 21, 1977.

2. Robert H. Langston, MD: Personal
interview on May 25, 2000.

3. Baird, W. David: Medical Education in
Arkansas, 1879-1978, 1979, Memphis
State University Press, p. 201.

4. Marvin, Horace N: Anatomy in
Arkansas’ Medical College 1879-1979,
The Journal of the Arkansas Medical
Society, 77:253-264, 1980.

5. Bruce, Thomas A., MD: Medical
School Deans, in Historical
Perspectives, edited by Max L. Baker,
PhD. The College of Medicine at the
Sesquicentennial, 1986, pages 45-46.

6. Obituary: W.C. Langston, Jr., Arkansas
Gazette, Nov. 23, 1943.

7. James Langston, MD: Personal
interview on May 25, 2000.

8. Thomas Langston, MD: Personal
interview on May 25, 2000.

286 • The journal

Volume 97

PEOPLE + EVENTS

HONORED

Dr. Haynes Elected
to Wildlife Society

Dr. W. Ducote Haynes, a
retired Searcy physician, has
been elected president of the
Arkansas Wildlife Federation,
a nonprofit hunting, fishing
and conservation organization.

Dr. Haynes graduated from
the University of Arkansas at
Fayetteville and received his
medical degree from the
University of Arkansas for
Medical Sciences. He took a
fellowship at the M.D. Ander-
son Cancer Center in Hous-
ton, specializing in radiation
oncology.

In 1976, Dr. Haynes was
named the first chief of staff
at the Central Arkansas
Radiation Therapy Institute.
He practiced at the Little
Rock CARTI location until
becoming medical director of
CARTI in Searcy in 1988.
He retired in 1996.

Student Group
Honored Nationally

The Arkansas Medical
Society Medical Student
Section (AMS-MSS) won
national honors at the Amer-
ican Medical Association’s
annual meeting in Chicago in
June. The medical students
were recognized for having the
greatest number of students per
capita who were organ donors.

The award was presented
as the AMA Medical Stu-
dent Section concluded its
1999 national community
service project, Organ Donor
Awareness.

The 2000 national com-

munity service project is
called the Children s Health
Insurance Program. Rebekah
Craig-Nunez, a second-year
medical student at the Uni-
versity of Arkansas for Medical
Sciences, is the committee
chairman.

The students are conduc-
ting a statewide outreach
program for ARKids First and
attempting to educate and sign
up as many children and
families for the program as
possible.

Dr. Strode Appointed
to Review Committee

Dr. Steven Strode of the
University of Arkansas for
Medical Sciences has been
appointed to a three-year
term on the Committee for
Review and Recognition of
the Accreditation Council
for Continuing Medical
Education, based in Chicago.

The CRR surveys, evalu-
ates and recognizes medical
societies to accredit intrastate
providers of CME. It also
recommends policy and
actions relevant to recognition
to the Council.

Physicians Receive
Awards from AMA

Each month the Ameri-
can Medical Association pre-
sents the Physicians Recog-
nition Award to those who
have completed acceptable
programs of continuing edu-
cation.

AMA recipients for
October are Dr. Joe D.
Hester of Magnolia, Dr.
Sandra M. Johnson of
Little Rock, Dr. Narayan-

swami Rangaswami of
Helena and Dr. Dowling B.
Stough of Hot Springs.

Dr. Smith Named
‘Community Pioneer’

Dr. Floyd A. Smith Jr.

of Trumann was honored as
a “community pioneer” at
the annual Wild Duck Fes-
tival on Oct. 6-7 in Tru-
mann. Dr. Smith served as
grand marshal of the Wild
Duck Festival Parade and
was honored at a reception.

OBITUARIES

Charles Anderson, MD

Dr. Charles Anderson,
91, of Pine Bluff, died Oct. 5.
Dr. Anderson graduated from
Emory University Medical
School in 1935 and interned
at Marine Hospital in New
Orleans.

He served in public
health service in Miami from
1936-37 and then joined the
Army Medical Corps. He
continued his education at
the New York City Cancer
Institute and Bellview Hos-
pital, specializing in radiology.

When called to active
duty in 1941, Dr. Anderson
became radiology consultant
for the 15 th Army Medical
Center in England. He retired
as a lieutenant colonel in
1946 and practiced radiology
in Pine Bluff until his
retirement in 1977. He was a
founding partner of Pine Bluff
Radiology Associates and was
a past director of the South-
east Arkansas Tumor Clinic.

He was preceded in death
by his wife, Marion Robson,

and two sons, James Ander-
son and William Anderson.
He is survived by a daughter,
Nancy Marion Hillman of
Cabot; three sisters; and
several grandchildren.

William ‘Bill’ Gamer, MD

Dr. William “Bill” Gar-
ner, 71, of Jonesboro, died
Nov. 12. He was a retired
radiologist.

Survivors include his
wife, Jackie Gamer; daugh-
ter, Jackie Perdew; two sons,
Bill Gamer Jr. and Dr. Matt
Garner; a brother, Judge
Harry R. Gamer; and nine
grandchildren.

James S. Garrison, MD

Dr. James S. Garrison,
62, of Conway, died July 31.
He was retired. Dr. Garrison
graduated from UAMS in
1964 and was an AMS
member since 1971.

Ernest Lee
Hutchison Jr., MD

Dr. Ernest Lee Hutchison
Jr., 82, of Heber Springs, died
Nov. 6. He was a graduate of
Hendrix College. Dr. Hutch-
ison helped found the Jefferson
Hospital in Pine Bluff, where
he practiced medicine for 30
years. He was a veteran of the
Navy, having served in the
Pacific during World War II.

Survivors include his wife,
Sharolette Hutchison of
Heber Springs; a son, E. Lee
Hutchison III of Memphis,
Term.; two daughters, Ann
Love of Springdale and Susan
Wells of Nome, Alaska; a sister,
Frances Harris of Richmond,
Va.; and six grandchildren.

Number 8

February 2001 • 287

William Ray Keadle, MD

Dr. William Ray Keadle,
73, of Glenwood, died Nov.
16. He was a graduate of
Hendrix College and the
University of Arkansas
Medical School. He is
preceded in death by his
brother, Randall Keadle, and
his son, James Ray Keadle.

Dr. Keadle is survived by
his wife, Alice Louise Keadle;
two daughters, Debra Ann
Cowart of Glenwood and
Karen LaDonne Hall of
Klamath Falls, Ore.; two
sons, William Edward Keadle
and Gary Wayne Keadle,
both of Little Rock; a sister,
Ruth Tolbert of Point
Cedar; a brother, James Ray
Keadle of Texas; and four
grandchildren.

J.F. Kelsey, MD

Dr. J.F. Kelsey, 78, of Fort
Smith, died Nov. 5. He was
a graduate of Kansas

University School of Med-
icine and was certified by the
American Board of Obstetrics
and Gynecology. Dr. Kelsey
practiced medicine in Fort
Smith with Obstetric and
Gynecology Associates from
1953 until his retirement in
1986. He was an Army vet-
eran of World War II and the
Korean War.

He was elected to the
Alpha Omega Alpha hon-
orary medical society and
was a member of the Amer-
ican Medical Association.
He was a past president of
the Sebastian County
Medical Society and the
Southeastern Obstetrical
and Gynecological Society,
and a fellow and past
chairman of the Arkansas
section of the American
College of Obstetricians
and Gynecologists. He
served on the staff of Sparks
Regional Medical Center

and St. Edward Mercy
Medical Center and was an
associate clinical professor of
the University of Arkansas
for Medical Sciences.

He is survived by two

daughters, Margo Roberts of
Dodge Center, Minn., and
Ellen Jacobi of Grand Forks,
N.D.; a son, Dr. Fred C.
Kelsey of Fairfax, Va.; and
eight grandchildren. ■

New Members

David Fort Jr., MD

Specialty: Resident-FP

601 W. Maple Ave., #102
Springdale, AR 72764
(501) 750-6585

Jason A. Franks, MD

Specialty: Resident-IM
4719 N. Lookout
Little Rock, AR 72205

John Frino, MD

Specialty: Resident-ORS

4301 W. Markham St., #531
Little Rock, AR 72205
(501) 686-5110

Robert Garcia, MD

Specialty: FP

306 N. Alabama
Crossett, AR 71639
(870) 364-4181

Martha G. Garrett-
Shaver, MD

Specialty: Resident-FP

460 W. Oak St.

El Dorado, AR 71730
(870) 862-2489

Caleb O. Gaston, MD

Specialty: Resident-FP

612 S. 12th St.

Fort Smith, AR 72901
(501) 785-2431

Glenn G. Gibbons, MD

Specialty: Resident-FP
612 S. 12th St.

Fort Smith, AR 72901
(501) 785-2131

Charles C.
Glendenning, DO

Specialty: FP

P.O. Box 130
Spiro, OK 74959
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Let Us Hear
From You!

You can now e-mail AMS
at the following addresses:

Main address:

ams @ arkmed.org
Ken LaMastus:
klamastus @ arkmed.org
Lynn Zeno:
zeno @ arkmed.org
David Wroten:
dwroten @ arkmed.org
Kay Waldo:
kwaldo @ arkmed.org
Journal:

j ournal @ arkmed.org

Plus. . . Visit our web site at:

www.arkmed.org

UAMS

Office of Continuing Medical Education...

Committed to Life-Long Learning

2001 Programs

Feb. 9-10 Geriatric Medicine Update

Location: The Holiday Inn Select, Little Rock, AR
Mar. 2-3 Neurology for the Non-Neurologist

Location: UAMS Pauly Auditorium, Ed III Bldg.

Mar. 11-16 Annual Conference of the UAMS-Prosper Meniere Society
Location: Inn at Aspen, Aspen, CO
Mar. 21-24 Southern Group on Educational Affairs
Location: Excelsior Hotel, Little Rock, AR
Apr. 5-7 Symposium on Critical Care and Emergency Medicine
Location: Arlington Resort Hotel, Hot Springs, AR
Joint Sponsors: UAMS and Univ. of Tennessee
Mar. 17 Symposium on Sleep Disorders

Location: UAMS/ACRC Walton Auditorium
Apr. 25 Best Practices in the Continuum of Care

Location: DoubleTree Hotel, Little Rock, AR
May 5 W.W. Stead Chest Symposium

Location: The Austin Hotel, Hot Springs, AR
May 11 The Diamond Conference

Location: The Riverfront Hilton Inn, North Little Rock, AR
May 18 The Diabetes Update 2001

Location: The Holiday Inn Select, Little Rock, AR

For additional information,

call the Office of Continuing Medical Education at (501) 661-7962
or check out our website, www.uams.edu/cmefd/cme2.htm

288 • The Journal

Volume 97

ARKANSAS RETREATS

Downtown Little Rock

Those who have not visited Little Rock recently will certainly be surprised by the rapid
and dramatic changes made downtown. Once a lonely, quiet area with little to offer,
downtown Little Rock has come alive with restaurants, night spots, museums and specialty
shopping.

The River Market provides a place to purchase everything from fresh seafood and
homemade pasta to gourmet coffee and barbecue. A Farmers’ Market, held Tuesdays and
Saturdays, offers homegrown goodies.

During the holiday season, the River Market is turned into a winter wonderland with
an open-air ice-skating rink and a light display.

Visitors can enjoy nightlife at the Underground Pub, the Pour House Bar and Grill,
The Flying Saucer or Sticky Fingerz, among others. For children, there is the Museum of
Discovery, featuring hands-on science and learning exhibits.

Lodging is not a problem downtown. The Excelsior, the Capitol Hotel and the
DoubleTree Hotel each offer luxury accommodations for business or pleasure.

Art lovers will delight in the newly expanded Arkansas Arts Center, while history buffs
can look forward to the reopening April 28 of the Arkansas Territorial Restoration, with its
new 45,000-SF museum center featuring galleries, a restaurant, a gift shop and more.

For more information about Little Rock’s attractions, call the Little Rock Convention
and Visitors Bureau at (501) 376-4781 or visit www.littlerock.com. ■

Number 8

February 2001 • 289

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290 • The Journal

Volume 97

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296 • The journal

Volume 97

Volume 97 Number 9
March 2001

Journal

OF THE ARKANSAS MEDICAL SOCIETY

Winner of the ASAE Excellence in Communications Award

CONTENTS

FEATURES

302 Merger Madness — Solo vs. Group Practices

In the past 10' 1 5 years, solo practices have slowly begun to
disappear, largely because of managed care. In response, doctors
have banded together to form large group practices. Still, some
physicians would rather practice on their own. The Journal
examines the advantages and disadvantages of being in group and
solo practices .

305 Raising the Bar

There’s no limit to what Heather Diemer, 26, of Little Rock, a
medical student and Arkansas Medical Society member, can
accomplish. She has high hopes of becoming a family doctor, with
an emphasis on adolescent medicine , and a public health
advocate. But those are just a few of her goals.

315 Study on Older Female Inpatients in Arkansas

Our special article examines whether there are significant
relationships between age, MDC, mortality, severity of illness,
risk of mortality and length of stay in women over 50 who are
inpatients in private, nonprofit Arkansas hospitals.

DEPARTMENTS

299 Commentary

Sue Chambers , MD

301 What We’ve Done
For You Lately
311 Case of the Month
307 A Closer Look at Quality
319 People + Events

321 Arkansas Retreats

322 Index to Advertisers

Bill Greene, CEO of Ortho Arkansas ,
sees the many benefits of large group
practices. — page 302

The most frequent “problem" area in
older female patients is the circulatory
system. — page 315

On the Cover: Dr. Joseph
Beck, a Little Rock medical
oncologist, proves that having
a solo practice can be done,
even though others have a
different opinion.

Cover Photo: Mark Wilson

Number 9

March 2001

297

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COMMUNICATIONS COORDINATOR

Judy Hicks

EXECUTIVE VICE PRESIDENT

Kenneth LaMastus, CAE

ASSISTANT EXECUTIVE VICE PRESIDENT

David Wroten

EDITORIAL BOARD

Sue Chambers, MD
Joseph M. Beck, II, MD
Lee Abel, MD
Samuel Landrum, MD
Jerry Kendall, MD
William Ackerman, MD

Pediatrics
Oncology
Internal Medicine
Surgery
Family Practice
Anesthesiology

EDITOR EMERITUS

Alfred Kahn Jr., MD

ARKANSAS MEDICAL SOCIETY
2000-2001 OFFICERS

Gerald A. Stolz, Jr., MD, Russellville
President

Joe Stallings, MD, Jonesboro
President-elect

Paul A. Wallick, MD, Monticello
Vice President

Lloyd G. Langston, MD, Pine Bluff
Immediate Past President

Carlton L. Chambers, III , MD, Harrison/Little Rock
Secretary

Dwight M. Williams, MD, Paragould
Treasurer

Anna Redman, MD, Pine Bluff
Speaker, House of Delegates

Kevin Beavers, MD, Russellville
Vice Speaker, House of Delegates

Joseph M. Beck, II, MD, Little Rock
Chairman of the Council

Established 1890. Owned and edited by the Ar-
kansas Medical Society and published under the di-
rection of the Council.

Advertising Information: Contact Stephanie
Hopkins, P.O. Box 3686, Little Rock, AR 72203;
(501) 372-2816.

Postmaster: Send address changes to: The Journal of
the Arkansas Medical Society, P. O. Box 55088, Little
Rock, Arkansas 72215-5088.

Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.

The Journal of the Arkansas Medical Society
( ISSN 0004- 1 858) is published monthly by the Arkan-
sas Medical Society, #10 Corporate Hill Drive, Suite
300, Little Rock, Arkansas 72205. Printed by The
Ovid Bell Press, Inc., Fulton, Missouri 65251.
Periodicals postage is paid at Little Rock, Arkansas,
and at additional mailing offices.

Articles and advertisements published in The Jour-
nal are for the interest of its readers and do not
represent the official position or endorsement of The
Journal or the Arkansas Medical Society. The Journal
reserves the right to make the final decision on all
content and advertisements.

298 • The Journal

Volume 97

COMMENTARY

AMS Efforts Defend
Children's Health Care

Sue Chambers, MD

Because a large number of Arkansas children are eligible for Medicaid,
the physicians who care for them have a vested interest in keeping
the Arkansas Medical Society alive and functioning.

Federal law guarantees Medicaid recipients equal access to health care.
On that basis in 1992, the AMS sued the state Department of Human
Services over severe cuts in Medicaid reimbursements that lowered the
number of physicians willing to take Medicaid patients. AMS won the
decision and a court decree that DHS must negotiate all fees for Medicaid
services with the AMS.

Arkansas’ Medicaid package for children and pregnant women is one
of the best in the nation. Because reimbursement is reasonable and prompt,
most physicians in the state are happy to accept Medicaid patients.

When Bill Clinton was elected president, the new governor, Jim Guy
Tucker, discovered that Medicaid was operating with a large deficit. By
proposing and shepherding the “soda pop tax,” the AMS, along with other
interested groups, lobbied the Legislature and prevented a 2% tax on
hospitals’ and physicians’ gross revenue, which was how the governor
wanted to make up the deficit. This means that a physician generating
$300,000 per year in gross revenue is saving $6,000 per year in taxes,
thanks to the AMS. You do the math; AMS dues are only $400.

Negotiations with DHS have secured payments of at least 65% of the
old Blue Shield allowable for adult Medicaid patient care and 75% for
care given to children and pregnant women.

In 1997, neonatologists were given a large boost when the AMS
took action against DHS for pricing three new procedure codes pertinent
to neonatology way below the agreed-upon rates. The Legislature forced
DHS to reprice them, effectively doubling the rates for Arkansas
neonatologists who care for large numbers of Medicaid-eligible, sick
newborns.

Last year, DHS decided to contract out all mental health services to
an entity called Value Options. By doing that, the agency divested itself
of responsibility for setting fees. Value Options attempted to contract
with psychiatrists and psychologists who would agree to fees about 30%
below the old Medicaid fees.

Mental health problems include AD/HD, autism, nocturnal enuresis
and behavioral problems such as school phobia. Primary-care physicians
could continue care for these illnesses, but they would be paid at the
reduced rate. AMS filed contempt-of-court charges, and DHS was forced
to reinstate the fees.

With the Legislature convening the second week in January, physicians
who care for children must rely on the AMS and its legislative efforts to
be in the forefront on issues pertaining to the health care of children and
their access to that care. It takes this larger organization of all physicians
to ensure that we keep the excellent package for children’s health care
that we now enjoy. ■

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Number 9

March 2001 • 299

AMS BENEFITS, INC.

A wholly owned subsidiary of the
Arkansas Medical Society
P.O. Box 55088

Little Rock, Arkansas 72215-5088
(501)224-8967
WATS 1-800-542-1058
FAX (501) 224-6489
“Available products include group
health, office package, professional
liability, home, auto, and more.”

INFORMATION FOR AUTHORS

The Journal of the Arkansas Medical Society
reserves the right to edit any material submitted.
The publishers accept no responsibility for
opinions expressed by the contributors.

MANUSCRIPT STYLE

REFERENCES

ILLUSTRATIONS

Illustrations should be professionally drawn
and/or photographed. Glossy black and white
photos are preferred. They should not be mounted
and should have the name of the author! s ) and figure
number penciled lightly on the back. An arrow
should indicate the top of the illustration. In photo-
graphs in which there is any possibility of personal
identification, an acceptable legal release must ac-
company the material. Up to four illustrations will be
accepted at no charge to the author(s). If more than
four are necessary, it is understood that the authorfs)
will be responsible for the reproduction costs.

REPRINTS

WHAT WE’VE DONE FOR YOU LATELY

Legislative Advocacy -
Everyday, All Day

By David Wroten

While the Legislature is still in town, I thought you might like to know what
a typical day is like during the legislative session.

Two members of our staff — Lynn Zeno, director of governmental affairs, and
Laura Harrison — are at the Capitol daily. However, the entire AMS staff is involved
one way or another to ensure that our legislative efforts are successful.

Each day actually begins the night before, when the many hills filed that day are
reviewed Bills that affect medicine are analyzed to determine the extent and nature of
their impact. Mornings begin at the AMS office, where appointments are scheduled,
bills on that day’s committee agendas are identified, and strategies for achieving our
legislative goals are discussed. Calls are made to seek advice and comment from AMS
members and leaders.

By 9 a.m., the action moves to the state Capitol, where we meet with our volunteer
physicians for the day. Each session, nearly 120 physicians will participate in the AMS
Doctor of the Day program, providing volunteer medical care to legislators and Capitol
employees. The AMS even maintains a temporary medical office on the third floor,
known as the Shuffield Infirmary, after the late Dr. Elvin Shuffield.

House and Senate committees, where most legislative battles are won or lost, begin
work at 1 0 a.m. AMS staff members attend these meetings daily, observing, providing
testimony and often scheduling physicians or patients to testify. We frequently provide
assistance to committee members by developing background papers and questions related
to special issues.

Access to legislators is a precious commodity. Because House members don’t have
private offices for meeting constituents or lobbyists, most lobbying has to take place
over meals, in the hallways of the Capitol and at social functions. For example, we
usually take the Doctors of the Day and their legislators to lunch, offering an excellent
opportunity to build relationships and bolster visibility.

A variety of activities takes place during the afternoons while the House and Senate
are in formal session. Legislators are called out of the chamber to gamer support for
AMS positions. Meetings are held with the Bureau of Legislative Affairs to draft bills
and amendments, with representatives of opposing interests to attempt negotiation or
compromise, and with lobbyists for other health care groups to work as a team for or
against certain bills. Once a week, the AMS hosts a meeting of these other health care
groups known as the Health Care Providers Forum to discuss legislative issues and to
develop strategies.

While most people are heading home, the evening work is just beginning. The
AMS and six other groups sponsor a hospitality suite, known as the “choo-choo room,”
for legislators each evening between 5-7 p.m. The choo-choo room, always in the
hotel where most legislators stay for the session, provides a non-confrontational
atmosphere where legislators can freely discuss issues, with no pressure from lobbyists
or constituents. Strong relationships and lifelong friendships, keys to legislative success,
are frequent results of evenings in the choo-choo room.

The AMS often takes groups of legislators to dinner to further build these
relationships. It could be a select committee such as Public Health, or groups such as
the women’s caucus or the minority caucus. While these dinners are primarily social in
nature, issues are discussed, and we promote our positions on key issues and bills.

This is just the beginning of what the AMS does for you each and every day during
the legislative session. The day ends as it began, with our group going over the hills
introduced that day and preparing for the next day’s work. ■

Number 9

March 2001 • 301

By Shelby Brewer

To Merge or Not to Merge?

Few

Physicians
are Going
it Alone
These
Days

here’s no doubt about it.The practice
of medicine has changed dramatically
in the past 50 years. For physicians
to keep up with the constantly changing
environment, one of the most recent trends
in medicine has been the banding together
of physicians from solo or small practices into
larger physician groups. And in this day of
managed care, it’s easy to see why physicians
don’t want to be left out in the cold.

But what's not so clear is whether this
recent merger storm will stick around. And the opinions
regarding these large mergers aren’t so easy to forecast, either
While some doctors still denounce the excessive
paperwork and the business atmosphere of large group
practices, the majority of them are singing the praises of easier
times when they no longer have to fly solo. Many doctors in
group practices say banding together gives them leverage in
an increasingly competitive environment, offers security and
stability, and increases their bargaining position with health
maintenance organizations.

Over the past 10-15 years, solo practices have dwindled, largely
because of the onset of managed care and capitated fees.

Bill Greene,

Bill Greene, CEO of Ortho-
Arkansas, believes there are
many benefits of merging
physician practices.

chief executive
officer of Ortho-
Arkansas, be-
lieves mergers of
physician practices
help ease the pain
of these changes in
health care.

“The
doctors

have

the ability to negotiate contracts better and respond to managed
care better” he said. "Being in a large practice also allows better
access to ancillary services. For instance, in our practice we
have several services, such as ambulatory surgery, physical
therapy, MRI and the cardiology clinic.”

Greene said large practices give doctors "economies of
function” — access to more capital to buy equipment and hire
better-trained staff. An easier lifestyle is another big benefit of
joining a large practice, Greene said. Arranging time off and call
rotations are not nearly the hassle they were when these
physicians were solo. And the complexity of the business side
of a private practice is often lessened in a large practice.

The Little Rock branch of OrthoArkansas — the result of
the consolidation of the Arkansas Bone and Joint Clinic, the
Little Rock Orthopedic Clinic, theTCS Orthopedic Clinic and
Orthopedic Associates — represents just one of many mergers
in the Little Rock area and across the state, Greene said.

"There have been a number of mergers in our market in
the last two years,” he said.1 The surgery group at Baptist Hospital,
most of the heart groups in town, the urology group — those
are just a few merged groups in the area. Most major specialties
have had at least one or more merger”

Is There a Risk?

In most of these large group practices, the doctors are
partners financially, or stockholders in the clinic and the clinic’s
assets, Greene said. The risk to doctors is minimal because the
large group has an "ongoing life,” he said.

"That’s one reason why many people don't go into private
practice,” he said. "In a solo practice, there's one owner and a
business, and when that owner gets ready to leave, there’s not
really anyone to sell it to, for the most part. That was not the
case when you had a lot of people wanting to practice solo.
Someone would come along and want to buy the older
physician’s practice, but that just doesn't happen anymore.”
Graduating from medical school and hanging your shingle
out for business is rare nowadays. Most surveys show that
new doctors are joining existing practices where the
risks aren't as high, Greene said.

"I think most of the remaining solo doctors
have developed a niche where they can
do exactly the kind of practice they
int and can generate enough
volume doing that
practice,” Greene
said. "They

have a reputation forthat niche, so they don't have to participate
on a broader scale in a group.”

Flying Solo

Developing a niche practice is what Dr Joseph Beck, a Little
Rock medical oncologist, has done. Dr Beck, whose niche is
treating HIV patients, went from a solo practice to a group
practice and is now back on his own — and, he said, much
happier

”1 was solo from 1 989 to 1 995, and I was happy and taking
good care of my patients. But at that time, just like everyone
else in the country, I started listening to the low rumble of the
train coming in that was this group-practice deal,” he said.

There was a mutual respect among several oncologists in
town who decided to merge and form the Little Rock Cancer
Clinic.

Looking back, Dr. Beck said he joined the group practice
partly out of fear "I looked around and saw that everyone was
doing it, and I thought to myself, what have I
missed here? If everyone else is doing it, then it
must be the right thing,’ ” he said.

Dr Beck said he and the other doctors who
joined thought that merging would give them
economies of scale and that they would be able
to cover more hospitals efficiently.

‘‘We were able to get by with fewer
employees for a while, and we had our economies
of scale, but what came clear to me over time
was that I didn’t feel like I could take care of the patients as well.

“Instead of me being the boss, there were four bosses, and
everybody had a different way of doing things. Nobody was
wrong, but it was just different. It was sort of like a marriage.”

In October 2000, Dr Beck left the Little Rock Cancer Clinic
and returned to private practice.

“Financially,” he said, “it's a little bit of a fright the first several
months, but for me, it has worked out and I'm happier And the
most important thing is I think I’m taking better care of the
patients.”

Better Patient Care

In his group practice, Dr Beck said, patients had a harder
time accessing their doctors. The nurses were handling more
calls than the physicians, which bothered Dr Beck.

“The patients don't want to call and hear; 'Punch five and
you’ll hear a nurse and maybe at the end of the day a doctor
will call back,' or; 'You can't talk to the doctor and the next
available appointment time is in four weeks because the waiting
room's so packed,’ " he said.

“And that’s part of what's wrong with health care today.
People think the doctors don’t care. They know that the profit
motive is No. I ,the convenience factor is No. 2, and then No. 3
is maybe the doctors can get around to treating the sick people."

OrthoArkansas’ Greene believes the large practices do
provide patients better care for the sole reason that they can
offer more in terms of service.

“In our case, in terms of facilities, we can offer better patient
care in terms of the scope of service, and we also have the

ability to offer a broader range of appointment times and a
variety of services that we didn't used to offer.”

For Dr. Beck, being able to have a one-on-one relationship
with his patients is extremely important.

“Being in a private practice allows me to keep my thumb
on everything,” he said. “I hear what goes on in the waiting
room, and if I hear them telling a patient that I can't see him for
three weeks but it was someone I told to call, then I can intercept
that. I’d like to think that I've cut out a lot of this electronic delay.
There's not this hierarchy.”

Is There an End in Sight?

Most health care experts agree that solo practices are quickly
becoming a thing of the past. The traditional mom-and-pop
way of taking care of patients has given way to a much larger
and structured system.

But Greene of OrthoArkansas believes much of the merger
madness is over

“I don't see as much perceived managed care pressure to
drive mergers now, as far as our market here is concerned.
Most of the logical combinations of doctors have already
occurred, and so there are not as many opportunities for more
mergers,” he said.

He said he doesn't foresee a big influence in this market to
drive multispecialty mergers. “That's more complex, politically,”
he said. “So I just don’t see the forces right now to do that.”

As for solo practices, Dr Beck agreed that they are slowly
diminishing.

“I'd like to be able to say that the future looks bright and
that people are going to be able to have solo practices, but I
don’t think I can. Medicine is going to become more of a
commodity. People are going to continue to want it quicker
and cheaper Ultimately, they'll get what they need, but it may
not be what they want,” he said.

Michael Helm, chief executive officer of Sparks Regional
Medical Center; said the forecast for independent practices in
Fort Smith looks the same as Little Rock.

“My experience in Fort Smith is that the independent
practice of medicine is declining and the larger group tends to
dominate,” he said. “And what I read is that the merging trend
tends to be leveling off. There was a significant amount of activity
in the '90s, so in our community, there’s not much left to
consolidate.”

Helm said Fort Smith's physicians had consolidated to retain
a voice in their medical practices.

“Small, independent practices have very little influence,
whereas larger practices have much more influence. That has
enticed physicians,” he said.

“Instead of me being the boss, there were four bosses, and everybody
had a different way of doing things. Nobody was wrong, but it was just
different. It was sort of like a marriage.” — Joseph Beck, MD

Number 9

March 2001 • 303

Helm said Fort Smith differs from Little
Rock in that most of the mergers have been
developed from the hospitals. He said there
had been very few independent
management companies and proprietors
behind the big mergers.

For instance, he said, Cooper Clinic and
Crawford Memorial Hospital inVan Buren
— much like Holt Krock Clinic and Sparks
in Fort Smith — have both acquired and
developed several group practices.

Dr Beck has his own theory why the
merging began.

"Greed on the part of some of the
insurance companies.They’re real happy to
open the envelopes that the premiums
come in, but they’re not so happy about
paying for the care," he said.

He said the merging began when
medicine became a business instead of a
vocation. “In the early '90s, it became
common that [the insurance companies]
wouldn’t take a doctor’s word that a
treatment was necessary, and so doctors had
to call and preauthorize treatments, and it
just sort of snowballed from there," he said.

Larger Than Life

Although there are benefits to a large
practice, Dr Beck said one of the biggest
drawbacks is how long it takes to make
decisions, often on simple things.

"In a large group practice, you can’t
go to someone and say, ‘I’m tired of using
this sort of paperclip. I want to use this
kind,’ ” he said. "There has to be a report
and a study done and a purchasing order
And then they have to be approved by
the CFO, and all the doctors have to get
together and approve it. Take that and
magnify it for every decision, whether it’s
a brand of gloves, brand of chemotherapy.
... For me, it was easier to get rid of all that
extraneous stuff and go back to a much
simpler model.”

Greene agreed the politics in a large
practice could be challenging.

"The relationship issues are more
complex, and the politics within the group
are certainly more challenging," he said.
"Groups have to make good, collective
decisions to be successful, and that’s not
always easy. But I think the positives of
merging far outweigh the negatives.”

Although a large practice didn’t suit Dr
Beck, he acknowledged that there are
benefits to that structure. Economies of

scale, group collaboration, the con-
venience of being able to take time off
and the ease of contracting with hospitals
and insurers are all perks.

"No doctor wants to become a
businessman, but I've had to again. I’ve
had to look at my costs carefully. But
there's really nobody who’s going to take
care of your business as good as you are,"
he said.

He said that although it is a benefit
that large groups have someone to take
care of their finances, it also can be
deceptive.

"The physicians don’t have much
training in economy and finances, so they
listen to the CFOs and bean counters.
But the stuff the CFOs tell them is like a
quote from my favorite author; Flannery
O’Connor: 'reasonable sounding but
wrong.’ And I think that’s what happens a
lot of times," he said.

A Thriving Relationship

The purchase of Fort Smith’s Holt
Krock Clinic by the city’s largest hospital
system is a good example of how large
groups can benefit both physicians and
the hospitals.

Sparks Regional acquired the clinic
in 1 999.The sale of the clinic was to settle
the war waged between its physicians and
the clinic’s owner PhyCor Inc., a physician
practice management company in
Nashville, Tenn. After Sparks acquired
Holt Krock, the Sparks Medical
Foundation was created.

“In our case, we were put in a
position of having to acquire the clinic
because of the instability, and the main
goal we achieved was the stability of our
medical staff,” Helm said. "There was no
significant market shift through the
acquisition."

Helm said that as a result of the
creation of the foundation, it is much
easier to contract with payors by having
a single signature authority for both the
physicians and the hospital. "And probably
the payors find it much easier as well. All
of our doctors participate in all the
contracts," he said.

Helm said that since the acquisition,
the foundation had recruited 45 new
doctors and is operating 54 practices in
Arkansas and Oklahoma at 38 locations.
There are I 20 physicians total, he said.

"We’ve had very good relationships
with our doctors," Helm said. "The main
benefits this acquisition has brought is
stability, efficiency, the creation of a very
seamless system of care for our patients,
the potential for our physicians to
practice more effectively and the ability
to deal with third-party entities more
effectively.”

Helm said all the doctors are
employed by the hospital and must abide
by the policies set forth by the foundation.
He said the clinics were able to select their
own practice name, however

"Some chose to include Sparks in their
name, but they all work under the umbrella
of the Sparks foundation," he said. "We do
all their billing and marketing."

The Future of Medicine

Helm believes the future of group
practices depends on the circumstances
in the community.

"Joining the large groups will work for
some but not others. Every institution and
every provider has to determine what the
best course of action is for their
community.There’s no simple answer"

He offered some advice to doctors
considering moving into a group practice.
"That individual has to find value in a group
or they won’t be happy," he said. "A
physician who's considering moving into a
group or being acquired by a hospital
should consider the pros and cons before
making the decision."

As for Dr Beck, he chooses the mom-
and-pop way of providing health care.

"I don't want to be the Wal-Mart — I
want to be the corner drugstore," he said.
"I can do almost as well, and maybe my
profit margins won’t be the same as Wal-
Mart's, but sometimes people don’t like
going to Wal-Mart. Sometimes they don’t
like waiting in a line of 30 people to buy
some laundry detergent. And maybe they
wouldn't mind going to a smaller place and
paying a few more pennies to get what they
want.

"I can’t criticize anyone forgoing into
one of those mergers. I did myself.
Doctors were just driven by fear when it
all began. It was like a defense mechanism.
There's that old saying that says, Those
who don’t embrace their fate are doomed
to be dragged by it,' and I think a lot of
doctors looked at it that way." ■

304 • The Journal

Volume 97

Meet Our Members

Heather Melissa Diemer

By Shelby Brewer

Getting a “C” in college chemistry didn’t discourage Heather
Diemer from following her dreams of entering medical
school. In fact, it challenged her to try even harder.

“It was during my freshman year of college, and I was told
by my adviser that if you can’t make an ‘A’ or ‘B’ in freshman
chemistry, then there’s no way you can go to med school,”
Diemer said. “So I spent the entire Christmas break frustrated
and upset.

“So the second semester, I took it and made one of the top
five grades out of a class of about 300. 1 was so mad that someone
told me I couldn’t do it, so I went to the extreme and even
ended up tutoring in chemistry for the next four years.”

Such challenges are what keep this 26-year-old med student
going.

A junior at the University of Arkansas for Medical Sciences,
Diemer is no stranger to the Little Rock area. She has lived in
Little Rock all her life — she has even lived in the
same house.

Diemer got her bachelor of science in
biology from the University of Arkansas in
Fayetteville. After graduating in 1996, she
stayed another year to work as a residence hall
director, which enabled her to take master’s
level classes in counseling.

But it turns out the job wasn’t all she
thought it would be. “After I started it, I ended
up hating it. It was just a lot of red tape, and
it really bogged me down, so by then I was
ready to go to medical school.”

So Diemer applied for and accepted a
research position at UAMS. She
returned home to Little Rock and
spent a year conducting re-
search and waiting tables at
Bennigan’s while applying
for medical school.

Diemer did her
research in the depart-
ment of family and
community medicine.

She worked with a
psychiatrist, helping
him develop ways to
detect mental illness
in the family practice
setting, and she also
did a work-flow study
of the clinic, which

Photo: Corbet Deary

Number 9

she said allowed her to follow doctors around all day while getting
paid.

“I was like a fly on the wall, observing everything, and they
treated me just like a med student. I really learned a lot,” she
said.

Finally, the time came for Diemer to interview for medical
school. “I walked out of there knowing I was going to medical
school,” she said. “In fact, they told me I was the best interview
candidate they had seen all day.”

Diemer received her acceptance letter on Valentine’s Day,
and she decided to give herself a little treat. “The very next day,
I bought a plane ticket to Europe. I promised myself that if I got
accepted, I would go to Europe for three weeks.”

Diemer made the trip alone. She wandered around Paris
and Germany and even got stuck in Spain.,“I was there when
all the trains went on strike. I got really stressed out. No one
spoke English, and my parents didn’t know I was by
myself. But I just wanted to see if I could do it. It
was awesome, but I’d never take a trip alone like
that again.”

Using the money she had saved from her
waitressing job, Diemer thinks she did pretty
well with her money. “I only spent about
$1,600 for three weeks. I stayed in youth
hostels and slept on the train a lot.”

Diemer, the middle among three sisters,
has plans of becoming a family doctor. But
the buck doesn’t stop there. She also wants
to specialize in adolescent medicine and,
after her residency, get a master’s in
public health and work in a fellowship
in adolescent medicine.

It was a summer camp that
initially sparked Diemer’s
interest in working with teen-
agers. “When I was a kid, I
was a camp counselor at
the Joseph Pfeifer Kiwanis
Camp in Little Rock that
serves youth at risk,” she
said. Diemer found out
about the camp from her
stepfather, who went
there when it was the
Boys Club camp. Diemer
started attending the free
camp at age 8.

“I was a product of

March 2001 • 305

jW-

stilgi

divorce and my family was poor, so I was
coined a youth at risk,” she said. When
she was 12, she became a counselor in
training, and, at age 15, she became the
youngest counselor the camp had ever
had before.

At the camp, Diemer met a man
whom she described as her life mentor.
His name is Sanford Toilette, and he is
the camp director.

“He would take me under his wing,
and he has this ability to look at someone
and see into them. And that was always
one of my goals — to look at someone
and see their motivations and soul. That’s
what 1 want to do with teen-agers. I want
to give them a chance and see them as
people,” she said.

Another inspiration in Diemer’s life
was her sixth-grade teacher, Becky
Cobum, who taught at Fuller Elementary.
“She was the first person who made me
want to pursue medicine,” Diemer said.

“She ended up dying of cancer. It was
my sixth-grade year when she got it,”
Diemer said. “She taught me so much.
She never underestimated our abilities,
and she was the first person I ever
experienced being sick. And I was so
frustrated because they couldn’t save her.

“I continued to visit her every year
until I was a senior. She had been in
remission, but it had come back full force
when I graduated. Since I was second in
my class at Mills High School, I got to
give a speech, and I talked about her in
my speech and dedicated it to her,”
Diemer said.

“She died that year, hut for my
graduation present, she gave me a bag of
really smooth stones, and she called them
her ‘wish stones.’ She told me that no
matter what happened, all I’d have to do
was mb the stones and she would always
be there to watch over me,” Diemer said.

While in high school and college,
Diemer was involved in both her school
and community. Some of her activities
included Students Against Drunk
Driving, student government, food
drives, the American Red Cross and
Meals on Wheels, and her involvement
continues today.

Diemer is an alternate delegate for
the Arkansas Medical Society’s student
section. As an alternate, she must be
available to attend the national

conferences of the American Medical
Association and vote on behalf of the
student section if the delegate cannot
attend. But Diemer has taken the position
to a whole new level.

Not only has she rewritten the bylaws
of the student section, but she has also
helped the president with organizing
conferences and helped bring a national
grassroots program called the Legislation
Action Committee to the Little Rock
chapter.

But Diemer said her biggest role has
been to encourage other students to join
the student section of the Arkansas
Medical Society.

“I try to educate more students about
the necessity of being involved at this
level. Right now is the time to start. We
need to he involved simply for the fact
that everything that goes on will affect
us 20 years down the road. All the laws
being passed, all the issues with HMO
and insurance companies will dictate how
we will practice medicine,” she said.

Diemer also said the society has
helped her build connections with
doctors across the state and nation, as well
as with other med students. Diemer is also
involved in the Arkansas Academy of
Family Physicians as well as many other
organizations.

Besides being a doctor, Diemer also
wants to be involved in politics. “I want
to be a practicing physician, hut I also
want my time to be divided by working
as a lobbyist in the political arena. I want
to be an advocate for public health
issues,” she said.

“I want to be the doctor that the
senator goes up to and asks, ‘Is this going
to be a good bill or will it affect doctors
negatively?’ ”

Diemer said she would like to do her
residency on the East Coast, maybe in
Virginia, North Carolina or South
Carolina. “I’ve looked at Boston, too, but
I don’t want to he that cold,” she said,
laughing.

Diemer also said she hopes to marry
and have children, although not getting
married is also one of her fears. “I’m scared
that I’ll have this great career and never
settle down and get married,” she said.

“When I first came to medical school,

I had three rules: never date someone in
my class, never he a pediatrician and

never marry a doctor. Well, I started off
dating someone in my class, and even
though I want to be a family doctor,
working with teen-agers is a big part of
pediatrics. And now I’m seeing a medical
student from New York that I met at an
American Medical Association meeting.”

What she’s looking forward to the most
about being a doctor is making an impact.

“I want to help [people] learn that
maybe what’s medically wrong with them
is related to the fact that their life is so
stressful. I want to teach them that they
need to treat all parts of their life. I believe
the body is guided by the mind and vice-
versa,” she said.

Diemer said she doesn’t want to work
in a city smaller than Little Rock, hut she
doesn’t want to live in a big city, either.
“Part of my passion is the outdoors, and
living in a city full of concrete would just
drive me crazy,” she said.

Probably the hardest part about
being in medical school is that
everything is always new, she said. “You
spend the first few days in a rotation,
learning what to do, and when you
finally learn it, it’s time for another
rotation. It’s very exhausting.”

Diemer said being in medical school
has also affected her sleep. “I used to joke
that I could sleep on the side of the
highway, but when I started medical
school, my stress got so high that I could
not sleep. My mind just never shuts down,
and sometimes I only get two hours of
sleep,” she said.

Fortunately, she has several methods
of dealing with stress. “I relax by working
out,” she said. “I’ve been doing step
aerobics for a while, and I try to work out
at least four nights a week. I also love to
mountain-bike and read suspense and
science-fiction novels.”

Diemer said she feels lucky to be a
woman medical student in this
generation. “The females before us have
had to fight so hard. They’ve literally
paved the way for us. We don’t have as
many injustices now,” she said.

She said the most critical issue today
regarding the medical field is deciding
who is going to practice medicine. “Is it
going to be the physician who has trained
for years and years and has the patients’
best interest at heart, or is it going to be
the HMO and insurance providers?” ■

B06 • The Journal

Volume 97

A CLOSER LOOK AT QUALITY

Managing Diabetes Mellitus

Arkansas Foundation
for Medical Care

Robert H. Hopkins, MD

The diagnosis and management of patients with dia-
betes mellitus are common in most adult and many
pediatric primary-care settings. Appropriate care can
prevent or delay morbidity due to neuropathy, vision loss, renal
failure, cardiovascular disease and amputation. In addition to
the physical costs of this disease to patients, it puts an im-
mense financial burden on individuals and society. Many health
care organizations, both public and private, have targeted
diabetes management as a
marker for quality health care.

The goal of this review is
to provide an update re-
garding the most recent
guidelines from the American
Diabetes Association (ADA)
on diabetes care and an
overview of identified quality
indicators for the management
of diabetes mellitus.

Diagnosis

Assignment of a par-
ticular type of diabetes is
probably less important than
making the diagnosis and
understanding the patho-
physiology of the disease in a
given individual. The ADA
expert committee has recom-
mended using the tenns Type
I and Type 2 to indicate the
most common forms of the
disease. Type 1 is the disease
most commonly originating
in childhood and is char-
acterized by absolute insulin
deficiency. It may be idi-
opathic or autoimmune in
origin. Type 2 is the most
common form of diabetes.

Patients manifest a com-
bination of inadequate insulin secretion and insulin resistance.
The other specific types of diabetes and associations with
other conditions constitute a small minority of diabetic
patients.

Impaired glucose tolerance and impaired fasting glucose
are categories that are clinically useful only as risk factors for
future diabetes mellitus and cardiovascular disease. These

conditions may persist in a given individual for an indefinite
period without meeting the criteria for diabetes.

Fasting plasma glucose and random plasma glucose mea-
sured on two separate days are recommended as the prin-
cipal screening methods for diabetes. Repeated testing is not
necessary to diagnose diabetes mellitus in patients with
unequivocal hyperglycemia and metabolic decompensation.
The 75 g oral glucose tolerance test may be used for diag-
nosis of diabetes mellitus; but its inconvenience for the pa-
tient and physician, limited
reproducibility and increased
cost reduce its utility in
screening the general popu-
lation. Some authorities re-
commend using the hemo-
globin Ale for diagnosis; this
approach is limited by cost and
standardization of the assay
across different laboratories.
The use of hemoglobin Ale for
monitoring of glycemic control
in most patients is uncontested.

A fasting plasma glucose >
126 mg/dl or a random plasma
glucose > 200 mg/dl in a patient
with symptoms of diabetes meets
the criteria for a provisional
diagnosis of diabetes and should
be confirmed on a separate day.
Fasting plasma glucose >110 mg/
dl and <126 mg/dl constitutes a
preliminary diagnosis of impaired
glucose tolerance. Screening of
patients beginning at 45 years of
age, or younger in the presence
of personal or family risk factors
for diabetes, is recommended to
reduce the large population with
undiagnosed Type 2 diabetes.

Management

Large prospective trials
have demonstrated that strict glycemic control potentiates
reductions in the absolute and relative risk of microvascular com-

Editorial Panel: William E. Golden, MD; Deborah L M arple, RN, BS, CPHQ; Donna S.
West, PhD; Nancy P. Archer, RN, BS, CPHQ.

Arkansas Foundation for Medical Care (AFMC) is the Peer Review and Quality Improvement
Organization for Medicare artd Medicaid in Arkansas. AFMC works collaboratively with providers ,
community groups and other stakeholders to promote the quality of care in Arkansas through
evaluation and education. For more information about AFMC quality improvement projects, call
800-272-5528, ext. 204.

Core Concepts

Hemoglobin Ale should be documented in the medical
record at least semiannually, along with an assessment
of glycemic goals.

Dilated retinal examination should be performed and
noted in the medical record at least every 1 2 months.

Fasting lipid profile should be measured annually, or
more frequently if indicated; treatment should be as
prescribed in the National Cholesterol Education Project.

Urinalysis should be noted annually. This should be
followed up as appropriate: if protein on urine dipstick,
albumin excretion should be quantified (protein/
creatinine ratio or timed urinary protein excretion), or if
dipstick for protein is negative, with urinary
microalbumin/creatinine ratio.

Foot examination with specific notation of sensation, skin
integrity and vascular status should be performed and
itemized at least annually. Patient education about foot
care and appropriate footwear/protection should also
be evident.

Pneumococcal vaccine should be given to all adults with
diabetes > 65 years of age.

Influenza vaccination annually, administered before
influenza season.

Dietary education should be documented in the medical
record.

Smoking status should be documented and, as

appropriate, counseling or referral given for smoking
cessation.

Exercise program should be given and documented in
clinical records.

Number 9

March 2001 • 307

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plications in both Type 1 and Type 2
diabetes. Intensive diabetes control,
unfortunately, also carries an increased
risk of more frequent and severe
hypoglycemic events. The degree of
glycemic control desired must be
individualized based on a risk/benefit
analysis in any given individual. Patients
and their physicians must collaborate in
establishing treatment goals for short- and
long-term glycemic control. Self-
monitoring should be instituted in most
patients with diabetes. Blood glucose
goals should be 80- 1 20 mg/dl before meals
and 100-140 mg/dl before bedtime. The
optimal frequency for home blood glucose
monitoring in Type 2 diabetes must be
individualized.

The frequency and intensity of
physician visits will necessarily vary
with the type of diabetes, glycemic goals
and the degree of achievement of those
goals, and the need for treatment
modification due to the complications
of diabetes and other medical illnesses.

Hemoglobin Ale should be
measured regularly to assess achievement
of metabolic goals. The absolute
frequency of monitoring will depend on
the degree of an individual patient’s
glycemic control; most authorities
suggest at least semiannual measure-
ment.

Hemoglobin Ale is not a valid
measure of glycemia in patients with
sickle-cell trait or other hemglobin-
opathies; measurement of other
glycosylated plasma products such as fru-
ctosamine may be used to assess control
in patients with these comorbidities.

Dilated retinal screening and a
thorough foot examination are
recommended annually in all adult
diabetics. Urine should be screened for
protein excretion yearly.

Adults with diabetes should also
have fasting lipid profiles measured each
year, and treatment should be
undertaken with a goal of LDL reduction
to < 100 mg/dl.

Aggressive blood-pressure control in
patients with Type 2 diabetes has been
demonstrated to reduce diabetes-related
death and vascular disease. Blood-
pressure control to 130/85 or less is
recommended in diabetics. ACE

308 • The Journal

Volume 97

inhibitors should be used in
antihypertensive regimens and in
patients with albuminuria unless
contraindicated. Daily aspirin and
efforts to correct other cardiovascular
risk factors are indicated in patients
with diabetes and evidence of vascular
or cardiovascular disease.

All patients with diabetes should
receive education on nutrition and
lifestyle modifications such as smoking
cessation and exercise. Patients with
severe or recurrent hypoglycemia or
hyperglycemia that is difficult to control
may benefit from referral to a
multidisciplinary diabetes-care manage-
ment program.

Arkansas Performance

Recent national evaluation of
Medicare outpatient claims data
indicates that compliance with these
recommended clinical strategies is
below national average. More than
40% of diabetics with Part B
Medicare insurance in Arkansas did
not receive any monitoring with the
hemoglobin Ale test. This put
Arkansas 49th in the country, as did
the low use of lipid screening (43%)
in this population. Slightly more than
two-thirds of Arkansas diabetic
patients with Part B received a dilated
eye examination within two years, and
that rate was 35 th best in the country.
Since these data were collected, the
Arkansas Foundation for Medical Care
has been engaged in public and
professional educational campaigns to
heighten awareness of these guidelines
and to change clinical behavior and
improve the state’s profile in the care
of diabetes.

Conclusions

Many of the advances in diabetes
management over the past decade are
directed toward stricter glycemic
control and surveillance for other
metabolic complications such as
hypertension, hyperlipidemia, vascular
disease and nephropathy. Medicare
audit data to date show suboptimal
rates of key indicators of quality care
such as annual hemoglobin Ale
measurement, dilated retinal exam-

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Continuing Medical Education
Upcoming Events

1. MEDICAL MALPRACTICE IN THE 21st CENTURY

Saturday, March 10, 2001

Half Day CME Seminar
Fayetteville, Arkansas

2. FISHIN’ & FACTS- PRIMARY CARE HOT TOPICS

April 27-29, 2001
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Fakeview, Arkansas

For more information, contact
Regional’s CME office at (501) 713-1823.

Sponsored by:

WASHINGTON

REGIONAL

MEDICAL CENTER

Fayetteville, Arkansas

MEDICAL DIRECTOR

Fittle Rock, Arkansas

Are you interested in joining one of the most recognized and suc-
cessful Managed Service Organizations in America? Practice Plus,
an affiliate of Arkansas Baptist Health, is seeking a Medical Director to
join our Senior Leadership Team to help coordinate clinical functions
in over 20 clinics. The successful candidate will have proven leader-
ship skills, clinical teaching and medical administration in a multiple
clinic environment. The selected candidate will be responsible for Stra-
tegic Leadership in regulatory compliance, physician/staff education
and clinical enhancements. Potential opportunities also exist for some
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If you are interested in joining a strong principle-centered leader-
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inations and lipid profiles. Nationwide,
and in Arkansas, increased compliance
with these indicators in day-to-day
practice should help reduce morbidity
and mortality for patients with diabetes
mellitus. ■

Author Affiliation

Dr. Hopkins serves as associate
program director for the Internal Medicine
and Pediatrics Residency Programs at the
University of Arkansas for Medical
Sciences. Additionally, he is an assistant
professor in the Department of Internal
Medicine and an instructor in the
Department of Pediatrics at DAMS . He
holds board certification in both internal
medicine and pediatrics and actively
practices in the Little Rock metro area. As
a pediatrician , he has extensive experience
in the promotion, education and
implementation of well child care and is an
excellent resource for pediatric standards of
practice.

References

American Diabetes Association
Position Statement: “Standards of
Medical Care for Patients with
Diabetes Mellitus.” Diabetes Care.
22(1999):S32-S41.

DCCT Research Group. “The Effect
of Intensive Insulin Treatment of
Diabetes on the Development and
Progression of Long-term
Complications in Insulin-dependent
Diabetes Mellitus.” New England
Journal of Medicine. 329(30
September 1993):977-86.

DeFronzo, Ralph A. “Pharmacologic
Therapy for Type 2 Diabetes
Mellitus.” Annals of Internal Medicine.
131(17 August 1999):281-303.

Haffner Steven M. Technical
Review: “Management of Dyslipidemia in
Adults with Diabetes.” Diabetes Care.
21(January 1998): 160-78.

31 0 • The Journal

Volume 97

jj»||C A S E t°hfe MONTH

Suspected Insulin Anaphylaxis
and Literature Review

Blake G. Scheer, MD — Karl V. Sitz, MD

Table 1 .

Time

(AM)

Units

NPH

Insulin

Route

Vital Signs
Before
Injection

Vital Signs
After
Injection

Reaction

08:00

0.0001

Intradermal

P=94

Unchanged

None

BP=1 24/80

R=18

08:30

0.001

Intradermal

P=94

Unchanged

None

BP=1 24/78

R=20

09:00

0.01

Subcutaneous

P=94

Unchanged

None

BP=1 20/80

R=20

09:30

0.1

Subcutaneous

P=96

P=weak/th ready

Odd feeling, head pruritus.

BP= 115/70

BP=70/-

brief loss of consciousness

R=1 8

R=12

10:00

Subcutaneous

Aborted

10:30

Subcutaneous

Aborted

11:00

Subcutaneous

Aborted

Abstract

Insulin allergy is a well-
documented complication of
insulin therapy. A 67-year-old
man presented with symptoms
suggestive of insulin anaphylaxis.

In an attempt to allow him to
continue insulin therapy, he
underwent a desensitization
protocol. During the protocol, he
again experienced symptoms
suggestive of anaphylaxis. An
analysis of his case is presented in
the context of current literature.

All physicians treating patients
with insulin should be aware of this
serious complication.

Case

A 67'year-old white man
with a history of chronic pan-
creatitis, now with diabetes after a partial
pancreatectomy in 1996, was initially treated
with the oral agents glimepiride ( Amaryl),
metformin (Glucophage), troglitizone
(Rezulin) and acarbose (Precose) without
control of his blood sugars.

About six months before his visit to our
clinic, he was started on insulin. His regimen
at the time was Humulin Regular 5 units
and NPH 10 units twice a day, which gave
him good control of his blood sugars.

However, after three months on this
regimen, he gave himself an injection
in the right thigh and immediately
became dizzy, dyspneic, diaphoretic,
pruritic and was near syncopal. He said
the symptoms lasted only a few minutes,

resolving before he could pick up a
phone and call for help. He felt normal
within 30 minutes.

He told his primary-care physician
about this and was told to stop his insulin
until he could be further evaluated for the
cause of die episode. By history, his reaction
seemed likely to be from anaphylaxis hut
could also be from hypoglycemia. He
resumed taking 10 mg glyburide twice a
day until his appointment.

He had no other medical problems and
his past surgical problems also involved a
cholecystectomy, a right inguinal hernia
repair and a tonsillectomy. He had no odier
known drug allergies and was taking
vitamin E, vitamin C and acetaminophen

in addition to insulin. His vital signs were
normal, and the only pertinent findings on
physical exam were a 2/6 systolic ejection
murmur at the apex, and a split S2 with
inspiration. His HbAlc was 9.36.

During his initial evaluation, the need
for insulin therapy was discussed. It was felt,
based on endocrinology consultant
recommendations, that desensitization to
10 units of NPH insulin would be most
appropriate.

Desensitization was chosen as the
initial procedure, since many patients on
insulin therapy have clinically insignificant
skin test reactivity, and toleration of insulin
therapy was the final clinical goal.

All of the risks and benefits, including

Number 9

March 2001 • 311

the risk of anaphylaxis, were discussed with
the patient, and he provided informed
consent.

Methodology

The patient began the desensitization
according to the protocol shown in Table
1. A peripheral IV was started, and a
resuscitation cart was placed in the room.
Serial dilutions of Humulin NPH insulin were
prepared using sterile saline. Insulin syringes
were used to inject 0.1 ml of each dilution
either intradermally or subcutaneously (as
called for in die protocol).

Each injection was carefully aspirated
to prevent intravenous injection. There
were no problems or adverse reactions
until after administration of 0.1 unit of
insulin subcutaneously. Within 10
seconds of administration, the patient said
he felt funny and also was itching on top
of his head. He briefly lost consciousness
and slumped over in his chair.

An ampule of D50 was immediately
administered, and, before epinephrine
could be injected, the patient regained
consciousness, and his vital signs returned
to normal within 1 0 minutes. There was
no wheal or erythema at the site of
injection. The procedure was aborted at
this point, and the patient was observed
for the next six hours before he was
allowed to leave.

We discussed the need to further
investigate this occurrence before restarting
insulin of any kind. The endocrinology
consulting team agreed and believed the
patient might benefit from troglitizone
again.

However, since the patient was
moving from this area, and considering the
risks involved if he was lost to follow-up, it
was decided to use glyburide alone.

Discussion

Insulin complications have been
documented since the first available
insulin was used in 1922. Although the
most common complication has always
been hypoglycemia, allergic reactions
were among the first observed. The
precise incidence is unknown, but 40-
50% of patients receiving animal insulin
preparations develop clinically
insignificant positive skin test reactivity
to the insulin selected for treatment.
Insulin reactions have been shown to be

IgE mediated in repeated reports with
immunologic laboratory testing, such as
ELISA and RAST, as well as with
provocative skin testing.1

Anti-insulin IgE has the ability to
attach to the outside of mast cells and
basophils and is otherwise not functioning
until the antigen is encountered again.
When insulin is reintroduced, the antigen
binds and cross-links the IgE on mast cells.
Immune response mediators are released,
such as histamine, prostaglandins,
leukotrienes, proteases (tryptase),
cytokines and other chemotactic factors,
which produce the clinical reaction.

These responses usually occur locally,
such as erythema and pain at the injection
site, but occasionally, systemic reactions
can occur.

Since animal insulin preparations were
the first used and first reported, it was
previously thought that the sensitivity was
caused by xenogenic (cross-species)
recognition of animal insulin. However,
insulin allergy has been documented,
although less frequently, since the advent
of human recombinant insulins.1

In one patient, it was documented that
a systemic IgE-mediated response
developed to her own endogenous insulin,
having symptoms in response to taking
sulfonylureas.2

The best explanation for the decrease
in sensitivity with the new insulins is
probably found in the processes of
preparing animal insulin for human use.
The insulin proteins are slightly denatured,
altering their tertiary structure, exposing
allergenic epitopes of the insulin molecule.
This would make them more accessible to
the immune response of the recipient.

Allergic reactions to other proteins
can mask themselves as insulin allergies.
One of the most common is that of
protamine, found in NPH (neutral
protamine Hagedom) insulin.3 Zinc is
another additive that has been
documented.4 Others include latex in
insulin syringes and the glue in insulin
pumps.5 These are just some of the known
peptide contaminants that have been
documented to elicit an immune response.

Other local reactions, such as
lipoatrophy and lipohypertrophy, also can
occur.6 Lipoatrophy is localized depression
of the skin in the area insulin has been
injected. This process could be immune-

related, since the incidence is less with
human insulin preparations. Lipohyper-
trophy is local swelling in areas of repeated
insulin injection. This problem is not only
a cosmetic problem, but it can alter the
ability of insulin to be absorbed in the
affected areas. The swelling usually subsides
modestly with a change in injection sites.
This was a main reason for initiating a
rotation of injection sites.

Patients can also develop edema as a
result of better glycemic control from the
sodium-retaining properties of insulin, but
it is usually self-limiting with a newly
diagnosed diabetic or with the initiation of
insulin therapy. Occasionally, diuretics are
used for a short time to relieve symptoms.

Did this patient have an anaphylactic
reaction to insulin?

There are some caveats to consider.
The first of these is the lack of an obvious
cutaneous reaction, such as the classical
wheal and flare response, during the
episode. The very young and the elderly
may have diminished skin reactivity
because of poorly functioning cutaneous
immunity.7

Other things that can decrease the
skin response include recent medicines,
such as antihistamines, poor potency of the
allergen given, or injections given too deep
to see the cutaneous response.8

This patient’s age and underlying
medical condition, along with the
subcutaneous administration of the insulin,
may have obscured a cutaneous response.
Measurement of serum tryptase levels may
sometimes confinn the release of mediators
associated with anaphylaxis.

Although the patient recovered
immediately after a rapid IV glucose
infusion, it is unlikely that a total of 0.12
units of NPH insulin given during the
procedure could cause hypoglycemia,
especially since he had eaten breakfast on
the morning of the procedure and his self-
reported fasting blood sugar at home was
120 mg/dl. His apparent immediate
response to the glucose was most likely
coincidental, since anaphylactic reactions
may be brief and self-limited. His reaction
resolved rapidly before epinephrine, the
drug of choice for anaphylaxis, could be
injected. In hindsight, epinephrine should
have been given instantaneously, with
glucose administration as a second
procedure.

31 2 • The Journal

Volume 97

Therefore, the patient likely had an
anaphylactic reaction to a component of
the insulin preparation. Skin testing to all
of the possible antigens, particularly regular
insulin, NPH insulin, protamine and latex
may have helped clarify the inciting
protein. In-vitro measurements of specific
IgE, such as RAST testing, could also have
been informative, particularly if skin testing
failed to give a diagnosis.4 These were
unable to be done since, soon after the
patient’s clinic visit, he moved out of state.
To our knowledge, no further evaluation
has been attempted at this time.

With a strong suspicion of an IgE-
mediated systemic reaction to insulin, the
patient had several options. First, he could
be treated more aggressively with oral
medicines, as we did on discharge with this
patient. If he continued to fail oral
medications, other preparations of insulin
could be attempted. Lispro insulin has been
shown to be tolerated in patients with
insulin allergy.9 Sheep-derived insulin has
also been used, but is very rare and not
readily available.10

It may also be possible to admit the
patient into the hospital under close
monitoring and attempt desensitization
again. It is very rare to find a patient
resistant to desensitization, but it has been
described. A last-resort possibility is the use
of prednisone to diminish the immune
response,2 but this treatment is undesirable
because of the many side-effects of long-
term steroid use, particularly in patients
with diabetes.

Since the patient has left our area, his
diabetes management is uncertain. We
discussed the need to consult an allergist
to further evaluate this rare and possibly
life-threatening reaction he demonstrated
in our office.

Conclusion

Insulin allergy is a known, well-
documented adverse reaction to insulin
therapy. Primary-care givers should be
alert in recognizing this condition.
Collaboration between allergy and
endocrinology specialists should lead to a
careful diagnostic and treatment plan.
With the use of alternative forms of
insulin therapy or desensitization, most
patients with documented systemic
insulin allergies are able to control their
blood glucose. ■

Dr. Scheer is with the division of allergy

and immunology at St. Louis University.

Dr. Sitz is with the Little Rock Allergy and

Asthma Clinic PA.

References

1. Patterson, R, Roberts, M, Crammer,
L. Insulin allergy: Re-evaluation after
two decades. Annals of Allergy. 64: 459-
62; May 1990.

2. Alverez, T, Rosenwasser, L, Brodie, T.
Systemic allergy to endogenous insulin
during therapy with recombinant
DNA (rDNA) insulin. Annals of
Allergy, Asthma, and Immunology.
76(3): 253-6; Mar 1996.

3. Dykewicz, M, Kim, H, Orfan, N, Yoo,
T, Liebennan, P. Immunologic analysis
of anaphylaxis to protamine com po-
nent in neutral protamine Hagedom
human insulin. Journal of Allergy and
Clinical Immunology. 93( 1 ): 1 17-125;
Jan 1994.

4- Bmni, B, Barolo, P, Gamba, S, Grassi,
G, Blatta, A. Case of generalized
allergy due to zinc and protamine in
insulin preparation [letter]. Diabetes
Care. 9: 552; 1986.

5. Towse, A, O’Brien, M, Twarog, F,
Brimon, J, Moses, A. Local reaction
secondary to insulin injection. A
potential role for latex antigens in
insulin vials and syringes. Diabetes
Care. 18(8): 1195-7; Aug 1995.

6. Porte, D, Sherwin, R. Insulin injection
complications: Ellenberg & Rifkin’s
Diabetes Mellitus. Second Edition,
Stamford, Appleton & Lange: 1219-
1220; 1997.

7. Middleton, E, Reed, C, Ellis, E,
Adkinson, N, Yunginger, J, Busse, W.
Factors affecting skin tests: Allergy:
Pnnaples and Practice. Fifth Edition, St.
Louis, Mosby: 433-437; 1998.

8. Wood, R, Phipatanakul, W, Hamilton,
R, Eggleston, P. A comparison of skin
prick tests, intradermal skin tests and
RASTs in the diagnosis of cat allergy.
Journal of Allergy and Clinical Immun-
ology. 103(5): 773-779; May 1999.

9. Lluch, B, Fernandez, M, Herrera, P,
Sastre, J. Insulin lispro, an alternative
in insulin hypersensitivity. Allergy.
54(2): 186-7; Feb 1999.

10. Kreines, K. Use of sheep insulin in
insulin allergy. Diabetes. 20( 11): 774-
5; Nov 1971.

'WMrnv/

Wzmzm

The Ark ansas Medical

HP Society is seeking
nominations for the 2001
Shuffield Award. The award
will he presented at the AMS
annual meeting in Hot
Springs May 4-5.

The Shuffield Award is
h year to honor I

given eacn year

tonor Jay

persons in Arkansas who

i j j.

have clone outstandn

ing work

on Lekalf of

community
health care. Potential
nominees include new spaper
reporters, television
personalities, government
officials, teachers or
volunteers in health-re lated
programs. Physicians and
mem hers of their immediate
families are not eligible to
receive this award.

For an application, call the

AMS at (501)224-8967.
or (800) 542-1058

Deadline is Feh. 28.

Number 9

March 2001 • 313

Arkansas Department of Health HIV/AIDS Surveillance

Summary

The cumulative total of HIV cases (1983-2000) is 4,833. Of
that number, 2,924 meet the AIDS case definition. Of the 2,924
AIDS cases reported since 1983, 1,335 (46%) have died.

HIV

in Arkansas -

September

30,

2000

Demographics

83-92

1993

1994

1995

1996

1997

1998

1999

2000

Total

Male

1.622

338

342

321

262

261

285

268

201

3,900

Female

288

933

Under 5

5-12

13-19

179

20-24

246

573

25-29

448

106

958

30-34

451

1,082

35-39

310

874

40-44

167

520

45-49

272

50-54

138

55-59

60-64

65+

White

1,234

264

243

252

186

179

185

191

138

2,872

Black

660

158

177

150

142

160

149

139

1,832

Hispanic

Other/Unknown

Male/Male Sex

1,049

230

213

176

153

133

163

152

2,362

Injection Drug

310

713

User (IDU)

M/M Sex + IDU

185

351

Heterosexual/

235

838

Known Risk

Transtusion

Perinatal

Hemophiliac

Undetermined

414

Total

1,910

427

431

410

339

353

355

353

255

4,833

100

AIDS in

Arkansas -

September

2000

Demographics

83-92

1993

1994

1995

1996

1997

1998

1999

2000

Total

Male

807

325

253

235

213

179

173

159

139

2,483

Female

441

Under 5

5-12

13-19

20-24

180

25-29

206

515

30-34

217

707

35-39

178

598

40-44

393

45-49

214

50-54

102

55-59

60-64

65+

White

658

264

189

173

145

130

115

108

1,880

Black

237

120

103

116

976

Hispanic

Other/Unknown

Male/Male Sex

547

228

163

140

129

102

104

1,592

Injection Drug

114

431

User (IDU)

M/M Sex + IDU

115

256

Heterosexual/

399

Known Risk

Transfusion

Perinatal

Hemophiliac

Undetermined

122

Total

905

388

295

271

267

225

213

189

171

2,924

100

For More Information

HIV/AIDS Statistics Mischelle Priehe, (501) 661-2323
HIV Services: Renee Patrick, (501) 661-2292
www.healthyarkansas.com

County

1983-

9-30-00

HIV Cases

Jut 99-
Jun 00

by County

County

1983-

9-30-00

Jut 99-
Jun 00

Arkansas

Lee

Ashley

Lincoln

Baxter

Little River

Benton

130

Logan

Boone

Lonoke

Bradley

Madison

Calhoun

Marion

Carroll

Miller

123

Chicot

Mississippi

Clark

Monroe

Clay

Montgomery

Cleburne

Nevada

Cleveland

Newton

Columbia

Ouachita

Conway

Perry

Craighead

Phillips

Crawford

Pike

Crittenden

217

Poinsett

Cross

Polk

Dallas

Pope

Desha

Prairie

Drew

Pulaski

1,573

Faulkner

Randolph

Franklin

St. Francis

Fulton

Saline

Garland

189

Scott

Grant

Searcy

Greene

Sebastian

269

Flempstead

Sevier

Hot Spring

Sharp

Howard

Stone

Independence

Union

155

Izard

Van Buren

Jackson

Washington

353

Jefferson

197

White

Johnson

Woodruff

Lafayette

Yell

Lawrence

Prisons

164

AIDS Cases by County

County

1983-

9-30-00

Oct 99
Sep. 00

Case Rate
per 100,000

1983-

County 9-30-00

Oct 99
Sep. 00

Case Rate
per 100,000

Arkansas

12.1

Lee-f

23.6

Ashley

0.0

Lincoln

0.0

Baxter

3.0

Little River-4-

15.3

Benton

2.2

Logan

0.0

Boone

3.1

Lonoke

2.0

Bradley

0.0

Madison

7.5

Calhoun

0.0

Marion

6.7

Carroll

4.4

Miller-4-

28.0

Chicot

13.4

Mississippi

2.0

Clark

9.3

Monroe

10.0

Clay

6.0

Montgomery

0.0

Cleburne

0.0

Nevada

0.0

Cleveland

0.0

Newton

0.0

Columbia

4.1

Ouachita

11.0

Conway

10.1

Perry ♦

31.0

Craighead

5.2

Phillips

0.0

Crawford

7.8

Pike

0.0

Crittenden-f

115

18.0

Poinsett

0.0

Cross

0.0

Polk

5.1

Dallas

11.2

Pope

5.7

Desha

13.4

Prairie

0.0

Drew

5.7

Pulaski-4-

962

17.0

Faulkner

2.4

Randolph

0.0

Franklin

6.0

St. Francis-4-

18.0

Fulton

0.0

Saline

0.0

Garland

123

11.0

Scott

0.0

Grant

0.0

Searcy

0.0

Greene

2.7

Sebastian^

174

23.0

Hempstead

5.0

Sevier

6.8

Hot Spring

10.3

Sharp

0.0

Howard

7.3

Stone

0.0

Independence 20

3.0

Union-4-

22.2

Izard

7.6

Van Buren

6.4

Jackson

0.0

Washington-4-223

14.0

Jefferson

118

12.4

White

3.1

Johnson

0.0

Woodruff

11.4

Lafayette

0.0

Yell

10.6

Lawrence

5.8

Prisons

n/a

■♦•Denotes top ten case rates 08/99-09/00 *Case numbers 1-3 are not indicated

314 • The Journal

Volume 97

SPECIAL ARTICLE

Older Female
Inpatients in
Arkansas

The Relationship of Age to MDC,
Mortality and Length of Stay in
Older Female Inpatients in a Private ;
Nonprofit Hospital in Arkansas

Melissa Johnson, MS — Lynette Duncan, MS — Andrea Rothenberger, M.ed., RN — Joanna Thomas, MD

Abstract

The purpose of this study was to examine age and Major
Diagnostic Categories (MDCs) and compare the variables
to mortality and length of stay among inpatient women age
50 and over.

Archival statistical data were obtained for 2,238
inpatients in a private, nonprofit hospital in 1998. The ages
ranged from 50 to 107 years old, with a mean age of 71.21
years.

Quantitative analyses were conducted to examine the
data from a private, nonprofit hospital and determine if there
were significant relationships between age, major diagnostic
category, length of stay, and mortality in older women.

The MDC distribution indicated that the highest
frequency of diseases and disorders were in the following
three systems: circulatory system, musculoskeletal system
and connective tissue, and the digestive system.

The average length of stay was 8.01 days. The 30 -day
readmission percentage and the 365-day readmission
percentage were 12.24% and 28.02%, respectively. The
mortality rate was 6%. In addition, 63.97% went home after
discharge, and 67.07% were Medicare recipients.

The risk of musculoskeletal diseases and disorders
increased with age (p=.0001). The conditional probability
of death was nearly nine times higher for the diseases of the
nervous system, myeloproliferative diseases and disorders,
poorly differentiated neoplasms and respiratory diseases.

As age increased, the probabilities of a long hospital stay
decreased. The mortality analyses found that the lowest
probabilities of survival were in categories of
myeloproliferative diseases and disorders, poorly
differentiated neoplasms, and infectious and parasitic
diseases.

According to current health statistics, our society is
getting older. Not only are people living longer, they are
accessing more health care (American Association for World
Health, 1999). Overall, the average life expectancy at birth
has been identified at 76.5 years. The female has a longer
life expectancy than the male, averaging 5.8 years longer.
The highest life expectancy has been identified in the white
female, who can expect to live to 79. The black woman has
the second-highest life expectancy, 74-7 years.10 Peters,
Kochanek, and Murphy reported an all-time-low age-adjusted
death rate for the United States and a continuing trend in
the decline in mortality for all age groups.11

With a growing number of people living longer, there is
a need to know about the most common health issues that
affect quality of life. The top three national causes of death
in older Americans were diseases of the heart, malignant
neoplasms, and cerebrovascular diseases/stroke.11 Arkansas
health statistics mirror the national statistics. In April 1999,
the Arkansas Department of Health reported that 30.5%
percent of all female deaths were caused by heart disease.
Malignant neoplasms were responsible for 20.1%, followed
by cerebrovascular diseases at 10.8%.'

Other than three Connecticut hospital studies that
explored the relationship of diagnosis code, mortality, and
readmission, research is meager in this area. 7,5,6 There is a
need for hospital-based research that addresses the diagnosis
categories and the relationship to age and other variables.

Purpose

The purpose of this study was to examine the most
frequent diagnosis codes for women over 50 years old and to
determine if there were significant relationships between age,

Number 9

March 2001 • 315

MDC, mortality, severity of illness, risk
of mortality, and length of stay.

Method

The subjects (n=2,238) were
obtained through a hospital admin-
istrative database and abstracted from a
proprietary decision-support software
product. Archival data criteria were:
1998, inpatient, females, 50 years and
older. The subjects had 3,255 inpatient
visits to the hospital. The ages ranged
from 50 to 107. Many of the patients
were admitted to the hospital more than
once within the calendar year. To avoid
violating assumptions of independence
in the statistical analysis, one
observation per patient was obtained.
This observation contained the final
diagnosis category, severity of illness, and
risk of mortality.

The length of stay for each patient
was computed as her total length of stay
within the year. All of the subjects had
a discharge date on or between the
calendar year dates of Jan. 1 to Dec.
31, 1998. Length of stay was chosen
as an indicator to assess the mean
length of stay of the subjects and to
measure any associations between age,
MDC, severity of illness, and risk of
mortality.

The MDC categories were identified
and analyzed with a frequency
distribution.3 The 30-day admission rate
was used to calculate the readmission
rate for the subjects. The 30-day
readmission rate has been used as a
quality-of-care indicator.8 The ordinal
severity of illness scores were based on
the 3M Corp.’s proprietary APR-DRG
methodology, which applies a 16-step,
clinically driven algorithm to determine
the value. The value rating was
0=Unknown, l = Minimum, 2=Mod-
erate, 3=Major, and 4=Catastrophic. The
risk of mortality scores were also derived
from the same methodology, which pla-
ces heavy reliance on clinical parameters
associated with the probability of death.2

The discharge disposition data were
based on the site of care, subsequent to
hospital discharge (i.e. home). The mor-
tality data were assessed to calculate the
mortality rate. The payor classes were
collected to identify the major

insurance/payor sources (i.e. Medicare).
The data were obtained in a Microsoft
Excel spreadsheet and transferred to the
SAS, Version 7.0, for statistical
analysis.4

Univariate frequency distributions
were used in the analysis. In addition,
multivariate baseline-category logit
models were used to study 1 ) the
relationship between MDCs and age,
risk of mortality, and severity of illness
and 2) the relationship between
discharge disposition and age, risk of
mortality, and severity of illness.

Logistic regression models were used
to study 1) the relationship between
severity of illness and MDC and age and
2) the relationship between mortality
and MDC, age, risk of mortality, and
severity of illness. A Cox proportional
hazards regression model was used to
analyze the relationship between
cumulative length of stay and age and
MDC. This model takes mortality into
account when considering length of
stay.

Results

Altogether, 2,238 subjects were
included in this study. The mean age
was 71.21 years old (SD + 12.00, range
50-107). The average length of stay was
8.01 days. The 30-day readmission
percentage and the 365-day readmission
percentage were 12.24% and 28.02%,
respectively. The mortality rate was 6%.
In addition, 63.97% of the subjects went
home after discharge, and 67.07% of the
subjects were Medicare recipients.

Out of 25 MDC categories, 73.51%
of the diseases and disorders were
found in the top five categories. The
MDC distribution indicated that the
five most frequent diseases and
disorders were in the following areas:
circulatory system (26.14%), mus-
culoskeletal system and connective tissue
(16.13%), digestive system (12.29%), res-
piratory system (11.62%), and nervous
system (7.33%). (See Table 1 )

The baseline-category logit model
was used to understand the relationship
between age and the MDCs. This model

Table 1 .

MDC Frequencies in Relationship to Age in Female
Inpatients over 50 in 1998.

Percent MDC # Human Body System, Diseases & Disorders Categories

26.14

Diseases St disorders of the circulatory system

16.13

Diseases St disorders of the musculoskeletal system St
connective tissue

12.29

Diseases St disorders of the digestive system

11.62

Diseases St disorders of the respiratory system

7.33

Diseases & disorders of the nervous system

5.23

Diseases & disorders of the female reproductive system

3.26

Diseases St disorders of the hepatobiliary system St pancreas

3.17

Diseases St disorders of the skin, subcutaneous tissue St breast

2.82

Infectious St parasitic diseases, systemic or unspecified sites

2.77

Endocrine, nutritonal St metabolic diseases St disorders

2.73

Diseases St disorders of the kidney St urinary tract

1.61

Mental diseases St disorders

0.94

Diseases St disorders of the ear, nose, mouth St throat

0.94

No MDC assigned

0.89

Injuries, poisonings St toxic effects of drugs

0.67

Diseases St disorders of blood, blood forming organs,
immunological disorders

0.63

Myeloproliferative diseases St disorders, poorly differentiated
neoplasm

0.45

Factors influencing health statistics St other contacts with
health services

0.22

Multiple significant trauma

0.18

Diseases St disorders of the eye

Category descriptions were based on The 1997-98 DRG Pocket Resource Guide. 1997.

316 • The journal

Volume 97

Figure 1. Predicted Probability of MDC in Relationship to Age

MDC 1

MDC 4

MDC 5

MDC 6

MDC 8

Risk of Mortality = 2 and Severity of Illness = 2

revealed a significant relationship
between the MDC, age, severity of ill-
ness, and risk of mortality (p=.0001).
The model was appropriate for the data
(lack of fit p- value 1 1 ). In this model,
the parameter estimates that were found
not to be significantly different from 0
were set to zero. A fixed moderate rating
value was used for the risk of mortality
and severity of illness to identify the
systems’ predicted probability of MDC.

The probability of a subject having
a circulatory system disorder or disease
was the highest, at a probability of .307 78.
(See Figure 1) While the diseases of the
respiratory system decreased with
age (.14617 to .08831), the
diseases of the musculoskeletal
system increased with age (.08928
to .25012). In addition, diseases
and disorders of the nervous
system increased slightly, and
diseases and disorders of the
digestive system decreased slightly.

The diagnosis categories and
age had an effect on the length of
stay based on the Proportional
Hazards Regression Model. In-
dicator variables were assigned for
each level of MDC, and these
variables and age were included in
the model. Backward selection
was used to determine which of
these variables should remain the
final model. Age and seven MDC

categories were the only variables that
showed a relationship to length of stay.

The MDC categories of the
nervous system, myeloproliferative
diseases and disorders, poorly
differentiated neoplasm, and the
respiratory system had equal para-
meters. These MDCs had the lowest
probability of a long length of stay.
Subjects in these MDCs had the
highest Hazard Ratio at 8.947. The risk
of dying for these subjects were over 8
times higher than all of the MDCs that
were found to be significant in this
study. The parameter estimates showed

that as age increases, the
probability of a long hospital stay
decreases.

The MDCs of the circu-
latory system, digestive system,
diseases and disorders of the
kidney and urinary tract had
equal parameters (Hazard Ratio
4-763). The two remaining
MDC categories were infectious
and parasitic diseases and the
“other” group. The “other”
contained all the other MDCs
that were not represented above.
The highest probability of a long
length of stay was in the “other”
category. The inclusion of the
indicator variable for infectious
and parasitic diseases violated
the proportional hazards assum-
ption, so the analysis was
completed by excluding this indicator
from the model and stratifying the data
by it. The subjects who were in the
seven identified categories had a lower
probability of a long hospital stay than
the subjects in the “other” MDCs.

The stepwise logistical regression
model determined that the estimated
probability of survival was related to age
and MDC. Figure 2 shows the rela-
tionship between age, diagnosis, and
mortality. The grouped MDC values in
terms of the effect on mortality were not
statistically different for mortality. The
lowest probability of survival was in

Figure 2. The Relationship between Age, Diagnosis and Mortality.

Diagnosis

lor 4

5 or 6 or 11

17 or 18

All Others

Number 9

March 2001 • 317

these categories: myeloproliferative
diseases and disorders, poorly differ-
entiated neoplasm, infectious and
parasitic diseases, and systemic or
unspecified sites.

The highest probability of survival
occurred in the “other” category. Equal
parameters grouped MDCs: circulatory
system, digestive system, and the
kidney and urinary tract. Another
group of the nervous system and the
respiratory system was created. The
lowest risks were in the “other”
category. The lack-of-fit p-value for the
model was .8842. MDCs were grouped
due to the fact that they were not
significantly different in terms of the
effect on mortality.

Stepwise logistic regression was
used to determine a relationship
between age, diagnosis and the severity
categories. The lack-of-fit p-value was
.9827. The probability of a more
severe diagnosis increases with age in
all MDCs. In addition, a baseline-
category logit model was used to
determine an association of discharge
to age (p=.0001). The model found
that as one gets older, the probability
of going home decreases.

Discussion

It is interesting that more than half
(54.56%) of the diseases and disorders
were in the top three MDCs (cir-
culatory, musculoskeletal/connective
tissue, and the digestive system). The
MDCs were chosen over the diagnosis-
related groups (DRGs) because of the
limited number of reference categories.
While there were 25 MDCs, there are
more than 500 DRGs.

The distribution of the MDCs was
not the same across the ages. Age,
severity of illness, and risk of mortality
were found to affect the distribution.
Circulatory diseases were the highest,
which has been shown in the national
and state statistics. The risk of
musculoskeletal diseases and disorders
increased with age.

The mortality analysis found that
the lowest probability of survival was
in categories of myeloproliferative
diseases and disorders, poorly
differentiated neoplasms, and in-

fectious and parasitic diseases. This
supports the fact that these diseases are
more fatal as one ages. A comparison of
MDC, age, and mortality indicated that
the probability of survival decreases with
age.

The probability of a more severe
diagnosis increased with age, and, as age
increased, the probability of going home
decreased. This supports NCHS (1996),
which reported that as age increased, the
rates of discharge and procedures
increased. The conditional probability
of death was nearly 9 times higher for the
diseases of the nervous system, myelo-
proliferative diseases and disorders, poorly
differentiated neoplasms, and respiratory
diseases. As age increased, the probability
of a long hospital stay decreased.

Conclusions

This study shows a relationship of
age and MDC in comparison to
mortality, length of stay, and severity.
The results of this study support the need
for more research and education in the
areas of circulatory and musculoskeletal
diseases and disorders in women. Also,
there should be more hospital-based
research that addresses the diagnosis
categories and the relationship to age
and other variables. Indeed, we do have
national and state statistics. Yet,
examining and sharing the results of the
data that each hospital have at their
disposal could teach us even more. ■

Johnson is a doctoral student and health
educator at the University of Arkansas.
Duncan is a statistical consultant with the
University of Arkansas. Rothenberger is
quality management director with
Washington Regional Medical Center. Dr.
Thomas is an assistant professor in the
department of family and community
medicine at the University of Arkansas for
Medical Sciences in Little Rock.

References

1 . Arkansas Department of Health.

( 1 999 ) . Mortality in Arkansas : 1997.
Center for Health Statistics and
Division of Vital Records. Little
Rock, Ark.

2. Computer Sciences Corporation
Healthcare Group. (1997). Users

Guide for the Comparative
Benchmark Analysis Software.
Framingham, Mass.

3. CHIPS. (1997). The 1997-98 DRG
Pocket Resource Guide. The Center
for Healthcare Industry Performance
Studies. Columbus, Ohio.

4. Hatcher, L. and Stephanski, E.J.
(1994). A step-by-step approach to
using the SAS system for univariate
and multivariate statistics. North
Carolina: SAS Institute.

5. Hennen, J., Krumholz, H.M., and
Radford, M.J. (1995a). Mortality
experience, 30 days and 365 days
after admission, for the 20 most
frequent DRG groups among
Medicare inpatients aged 65 or older
in Connecticut hospitals, fiscal years
1991, 1992, and 1993. Connecticut
Medicine, 59 (3), 137-142.

6. Hennen, J., Krumholz, H.M., and
Radford, M.J. (1995b). Twenty most
frequent DRG groups among
Medicare inpatients age 65 or older
in Connecticut hospitals, fiscal years
1991, 1992, and 1993. Connecticut
Medicine, 59 (1), 11-15.

7. Hennen J., Krumholz, H.M.,
Radford, M.J., and Meehan, T.P.
(1995). Readmission rates, 30 days
and 365 days postdischarge, among
the 20 most frequent DRG groups,
Medicare inpatients aged 65 or older
in Connecticut hospitals, fiscal years
1991, 1992, and 1993. Connecticut
Medicine, 59 (5), 263-270.

8. Marcantonio, E.R., McKean, S.,
Goldfinger, M., Kleefield, S.,
Yurkofsky, M., and Brennan, T.A.
(1999). Factors associated with
unplanned hospital readmission
among patients 65 years of age and
older in a Medicare managed-care
plan. The American Journal of
Medicine, 107 (1), 13-16.

9. National Center for Health
Statistics. (1999a). Ambulatory and
inpatient procedures in the United
States, 1996 (PHS Publication No.
98-1798 pp. 124).

10. National Center for Health
Statistics. (1999b). Deaths: Final
Data for 1997. 47 (PHS Publication
No. 19-018 pp. 108).

11. Peters, K.D., Kochanek, K.D., and
Murphy, S.L. (1998). Deaths: Final
data for 1996. National Vital Statistics
Reports, 47 (9), 1-100.

318 • The Journal

Volume 97

PEOPLE + EVENTS

RETIREMENT

Sheridan Physician
Honored at Retirement

Dr. Jack Irvin of Sher-
idan was honored Nov. 4 by
the residents of Grant
County on the occasion of his
retirement. Friends, patients
and family members paid tri-
bute to Dr. Irvin for his 53
years of service to the
community.

In addition, Sheridan
Mayor Joe Wise declared Nov.
13 — Dr. Irvin’s birthday and
the date of his retirement —
Dr. Jack Irvin Day.

Dr. Irvin graduated from
Sheridan High School in
1938. He continued his
education at Henderson State
University in Arkadelphia,
the University of Arkansas for
Medical Sciences and Baylor
University Hospital in Dallas.
He completed his residency in
pathology at Bowman Gray
Hospital in Winston-Salem,
N.C.

Dr. Irvin began his prac-
tice in Sheridan in 1947, at
times practicing out of his
home. In 1956, he built his
clinic on High Street.

He and his wife, Marge,
have three children and three
grandchildren.

HONORED

Boone County Doctors
Honor Elected Officials

The Boone County
Medical Society hosted its
annual appreciation dinner
for area elected officials in
November. Randy Laverty,
outgoing chairman of the

Public Health, Welfare and
Labor Committee of the
state House, received a
plaque from the Society and
the Arkansas Academy of
Family Physicians. Atten-
dance at the dinner was 86.

Chamber Honors
Searcy Doctor

Dr. Porter Rodgers Jr. has

received the Medical Profes-
sional of the Year Award from
the Searcy Chamber of

Commerce Quality of Life
Committee. Dr. Rodgers was
chosen for his contributions to
the health and quality of life
of residents of Searcy. The
award was presented at the
committee’s annual banquet
Nov. 20.

Physicians Receive
Awards from AMA

Each month, the Ameri-
can Medical Association
presents the Physician’s

Recognition Award to those
who have completed accep-
table programs of continuing
education.

AMA recipients for
November are Dr. Roger
Willis Alderson of Rogers,
Dr. Carlos Anaya of El
Dorado, Dr. James Henry
Arkins of Bentonville, Dr.
Joe Henry Dorzab of Fort
Smith, and Drs. Frank
Hsioh-ti Ma and Josue
Montanez of Little Rock.

OBITUARIES

Donald G. Browning Sr., MD

Dr. Donald G. Browning Sr., 64, died
Dec. 2.

Dr. Browning, a retired gastroenter-
ologist, was a graduate of Hope High School,
Henderson State University at Arkadelphia
and the University of Arkansas for Medical
Sciences. His internship was at Brooke Army
Hospital in San Antonio, and his residency
was at Fort Benning, Ga. He completed a GI
fellowship at U AMS in 1970-71.

After serving in the Army in Germany
and attaining the rank of major, he entered
private practice in Little Rock with Dr. Jerome
Levy and Dr. T.J. Smith.

In 1971, Drs. Browning and Smith
founded Gastroenterology Associates PA, the
first GI subspecialty practice in Arkansas.
They, along with Dr. Robert C. Power, were
instrumental in developing gastrointestinal
laboratories at St. Vincent Infirmary Medical
Center, Baptist Medical Center and Baptist
Memorial Medical Center.

Dr. Browning was also a member of the
American Medical Association, the Pulaski
County Medical Society and the American
Society of Gastrointestinal Endoscopy. He
was a fellow of the American Society of
Addiction Medicine, through which he
worked with physicians and others who
struggled with alcoholism or drug addictions.

Survivors include his wife, Jo Ann Russell

Browning; his mother, Floyce Browning ; two
sons and daughters-in-law, Dr. Don and
Sundee Browning J r. of Atlanta; Dan and Tara
Browning of Germantown, Tenn.; one
daughter and son-in-law, Joan and Mike Foster
of Atlanta; three brothers and sisters-in-law,
Conrad and Polly Browning of Little Rock,
Bill and Sandra Browning of Emmett, Ark.,
and the Rev. Jerry and Ann Browning of
Magnolia; a sister-in-law, Jutta Browning of
Aurora, Colo.; and eight grandchildren.

He was preceded in death by his father,
Grady Browning, and his brother, Maj. Larry
Browning.

Evans Z. Hornberger Jr., MD

Dr. Evans Z. Hornberger Jr., 82, died Dec.
1 in Fort Smith.

From 1946-50, Dr. Hornberger studied and
practiced internal medicine in Milwaukee. He
then moved to Fort Smith, where he had a
private practice from 1950-75. He served as
medical director of Sparks Regional Medical
Center from 1975-86. He retired in 1986.

He was also a member of the American
Medical Association and the Sebastian
County Medical Society.

Bom in Omaha, Neb., Dr. Hornberger
graduated from the University of Nebraska
College of Medicine in 1942. He served in
the Army from 1943-46 and was discharged
after attaining the rank of major. He served
with the 16th Armored Division at Fort

Number 9

March 2001 • 319

Chaffee and with the 35th Infantry Division in Europe in World
War II. He was wounded in action and received a Purple Heart
and a Bronze Star.

He was an elder and trustee of the First Presbyterian Church
in Fort Smith and a volunteer for several charitable organzations,
including Meals on Wheels.

He is survived by his wife, Nancy Eads Homberger; his son
and daughter-in-law, Robert E. and Pam Homberger of Fort
Smith; his daughter and son-in-law, Ellen and Conrad
Masterson Jr. of Houston; one brother and sister-in-law, Dr.
John and Joan Homberger of Manning, Iowa; four grand-
children; and two great-grandchildren. ■

New Members

Donna M. Graham, MD

Specialty: PDA

10310 W. Markham St., #222
Little Rock, AR 72205
(501) 227-5589

Ehsan M. Hadi, MD

Specialty: Resident-FP

4010 Mulberry St.

Pine Bluff, AR 71603
(870) 541-6010

Martin A. Hannon, MD

Specialty: Resident-FP

612 S. 12th St.

Fort Smith, AR 72901
(501) 785-2431

Sally S. Harms, MD

Specialty: Resident-PTH

4301 W. Markham St.

Little Rock, AR 72205
(501) 686-5444

Paul T. Harrington, MD

Specialty: ID

6801 Rogers Ave.

Fort Smith, AR 72913
(501) 478-3580

Scott Harton, MD

Specialty: Resident-FP

460 W. Oak St.

El Dorado, AR 71730
(870) 862-2489

James M. Hawk, MD

Specialty: GP

W. 715 Sherman
Harrison, AR 72601
(870) 741-8247

Prabhat K. Hebbar, MD

Specialty: Resident-IM

4301 W. Markham St.

Little Rock, AR 72202
(501) 686-5162

Muhannad M. Heif, MD

Specialty: Resident-IM

4710 Sam Peck Road, #2148
Little Rock, AR 72223

John K. Heifner, MD

Specialty: NPH

500 S. University Ave., #2 19
Little Rock, AR 72205
(501) 664-9881

Brent E. Holt, MD

Specialty: Resident-FP

2907 E. Joyce Blvd.
Fayetteville, AR 72703
(501) 521-8260

Michael Tzuoh Hong, MD

Specialty: OBG

3104 Apache Drive
Jonesboro, AR 72401
(870) 972-8788

Hossam Ibrahim, MD

Specialty: END

180 Medical Park, #202
Hot Springs, AR 71901
(870) 625-7400

Phillip C. Jackson, MD

Specialty: Resident-FP

2907 E. Joyce Blvd.
Fayetteville, AR 72703
(501) 521-8260

Jana M. Jaderborg, MD

Specialty: GS

724 Deaver St.

Springdale, AR 72764
(501) 751-3202

William M. James, MD

Specialty: Resident-IM

4301 W. Markham St.
Little Rock, AR 72205
(501) 686-5444

ARKANSAS

EMERGENCY MEDICINE

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320 • The Journal

Volume 97

Ridgecrest Resort on Bull Shoals Lake

For some of the best views of Bull Shoals Lake
and the Ozark Mountains, visit Ridgecrest Resort
in Midway. Located 15 minutes from Mountain
Home, this scenic spot offers a host of amenities
for the traveler looking to get away from it all.

Cottages feature a fully equipped kitchen,
cable television, barbecue kettles and lawn chairs.
Visitors also can enjoy fantastic views from the
comfort of their cottage.

A play area and game room will keep the kids
busy with swings, outdoor toys, two video games,
a ping-pong table and board games. The common
area has a large deck, barbecue grill and seating.
Visitors can take a short walk to the swimming
dock or soak in the indoor hot tub.

Visitors are welcome to bring their own boat
or to rent one when they arrive. Ridgecrest has
two pontoons and several fishing boats for rent,
either for four and six hours or by the week. Daily

prices range from $20-$85, with weekly rates from
$120-1450.

Honeymooners, or couples just wanting a little
extra pampering, can stay in the honeymoon suite,
which has a fireplace, Jacuzzi and private deck.

Nearby Mountain Home offers conveniences
such as grocery stores and restaurants, as well as
movie theaters and two 18-hole golf courses.

For those wanting a little city life along with
the scenic beauty, Branson, Mo., with its live music
and shopping malls, is two hours away.

Daily rates for cottages range from $58-$64 for
one bedroom, $73 for two bedrooms and $102 for
three bedrooms. The honeymoon suite is $85 a day.
Weekly rates also are available. ■

Ridgecrest Resort, 971 Howard Creek Road,
Midway, Ark. 72651. For information, call (870)
431 '5376 or visit www.bullshoals.com/ridgecrest.

ADVERTISERS INDEX

AMS Benefits Inc 300

Arkansas Business. Com Back cover

Arkansas Financial Group Inc., The 296

Arkansas Foundation for Medical Care .... Inside front cover

Asti, William Henry, AIA 299

Central Flying Service 308

Farmers Insurance Group 308

Fiser Hummer 296

Little Rock Medical Associates 309

Maggio Law Firm 322

Medical Practice Consultants Inc 309

MedPlus Quotes 299

Metropolitan National Bank 298

Micheal Munson, A.G. Edwards & Sons Inc. . Inside back cover

PhyAmerica Physician Services Inc 320

Practice Plus 310

Pro Travel 298

State Volunteer Mutural Insurance Co 295

Washington Regional Medical Center 310

Special Publications
Publisher
Brigette Williams

Production and Circulation

Coordinator

Jeremy Henderson

Special Publications
Editor- in -Chief
Natalie Gardner

Managing Editor
Shelby Brewer

Copy Editor
Donna Schratz

Editorial Assistant
Susan Van Dusen

Sales Manager
Stephanie Hopkins

Account Executives
Jason Carson
Liz Earlywine

Editorial Art Director
Irene Forbes

Photographer
Mark Wilson

Advertising Coordinator
Kristen Heldenbrand

Marketing Assistant
Mitzi Tiffee

Database Administrator
Andrea Martin

Advertising Assistant
Greg Duszota

A ARKANSAS BUSINESS
PUBLISHING GROUP

Director of Design
and Circulation
Virgeen Healey

Chairman & Chief Executive Officer
Olivia Farrell

President and Publisher
Jeff Hankins

Director of Marketing Executive Vice President

Allison Pickell Sheila Palmer

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322 • The Journal

Volume 97

2001

Investment

Outlook:

The Bull Should Have
More Room To Run

Contributed by:
Micheal D. Munson
Senior Vice President— Investments
A.G. Edwards
1501 N. University, Suite 100
(501) 664-9135

Wr ithout a doubt the year 2000 has been
turbulent for the financial markets.
While the major stock market indexes
enjoyed huge gains early in the year, the reality
of slower earnings growth, higher energy prices
and presidential election turmoil all helped the
market head south. Along with these issues,
the Federal Reserve raised interest rates to slow
a red-hot economy and prevent probable infla-
tion, which scared already-nervous investors.
So what does 200 1 hold in store for the economy
and the market? Here’s one set of perspectives:

- Economy Should Slow But Still Grow. While
economic activity should continue to slow go-
ing into 2001 its growth should also continue. Some experts expect the real gross domestic product (GDP)
to grow approximately 2.9% compared to an average yearly growth of 4.5% for the previous four years.
Analysts have projected a slower economy in the first months of the year with a moderate strengthening
later in 2001. Meanwhile inflation as measured by the Consumer Price Index is expected to drop to 2.5% in
2001, down from 3.3% in 2000.

- History Forecasts Lower Interest Rates. The Federal Reserve, once concerned with an overheating
economy, has seen the pace of activity slow in the latter part of 2000. This means we will most likely see the
Fed cut interest rates, probably early in the year. Why? The economy historically endures three stages
during a slowdown. The first stage is after a peak in economic momentum when the Fed has raised interest
rates to prevent rapid economic growth from triggering higher inflation. The second is a continuation of a
slowdown while economic growth is moderating. The current U.S. economy is likely to be in the third stage
in the beginning of 2001. In this stage the economy experiences a considerable slowdown and the Fed
recognizes it no longer needs to be restrained by high interest rates. The Fed typically cuts interest rates in
this third stage to re-stimulate the economy to a healthy pace of growth. While past performance cannot
guarantee future results, the last time we saw this type of economy was in 1995, which was a good year for
the financial markets.

- Stocks Expected To Rebound. After 18 months of stock market corrections some experts believe we are
finally entering a season of recovery. Thanks to a more benign economy, lower interest rates, continued
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Arkansas Foundation for Medical Care

Volume 97 Number 10
April 2001

Journal

OF THE ARKANSAS MEDICAL SOCIETY

Winner of the ASAE Excellence in Communications Award

CONTENTS

FEATURES

335 Cigarette Smoking Bills Are a Major Focus at
“Day at the Capitol”

At the Arkansas Medical Society’s “Day at the
Capitol ” on Jan. 31 , doctors, spouses, medical
students and clinic managers from across the state
voiced their views on important legislative issues
relating to public health.

338 A Long Journey

Drs. Parthasarathy Vasudevan, a urologist, and wife
Kanaka Vasudevan, an anesthesiologist, describe the
path that led them from India to Helena, Ark. , and the
challenges of being both married and doctors .

351 Pediatric Injuries Resulting from Use of
All-Terrain Vehicles

Each year, 20,000 children are injured while operating
all-terrain vehicles. Although ATV injury information in
Arkansas is limited, our special article examines the high
injury rates in the 75 Arkansas counties on the basis of
prehospital emergency encounter reports .

DEPARTMENTS

331

Commentary

Lee Abel, MD

lt>‘ :;Y§ j

333

What We’ve Done

For You Lately

340

Loss Prevention

: I til 1

1 “*g ggfsra 1

343

Cardiology Report

1 * m

l *ry ■

346

Radiology Report

349

A Closer Look at Quality

354

People + Events

fm .

357

Arkansas Retreats

358

Index to Advertisers

India natives Drs. Parthasarathy
Vasudevan and Kanaka Vasudevan
say they’re happy to be practicing in
Helena. — page 338

Studies indicate that higher EMS
encounter rates with child-ATV
incidents occur in rural Arkansas
counties. — page 351

On the Cover: Dr. Robert Floss
(from left) , a family practice
physician in Hampton, Rep. Larry
Teague of Nashville and Dr. John
Heamsberger, a cardiovascular
surgeon in Little Rock, discuss
medical-related bills at the
Arkansas Medical Society’s "Day
at the Capitol.’’

Cover Photo: Mark Wilson

Number 10

April 2001

329

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COMMUNICATIONS COORDINATOR

Judy Hicks

EXECUTIVE VICE PRESIDENT

Kenneth LaMastus, CAE

ASSISTANT EXECUTIVE VICE PRESIDENT

David Wroten

EDITORIAL BOARD

Sue Chambers, MD
Joseph M. Beck, II, MD
Lee Abel, MD
Samuel Landrum, MD
Jerry Kendall, MD
William Ackerman, MD

Pediatrics
Oncology
Internal Medicine
Surgery
Family Practice
Anesthesiology

EDITOR EMERITUS

Alfred Kahn Jr., MD

ARKANSAS MEDICAL SOCIETY
2000-2001 OFFICERS

Gerald A. Stolz, Jr., MD, Russellville
President

Joe Stallings, MD, Jonesboro
President-elect

Paul A. Wallick, MD, Monticello
Vice President

Lloyd G. Langston, MD, Pine Bluff
Immediate Past President

CarltonL. Chambers, III, MD, Harrison/Little Rock
Secretary

Dwight M. Williams, MD, Paragould
Treasurer

Anna Redman, MD, Pine Bluff
Speaker, House of Delegates

Kevin Beavers, MD, Russellville
Vice Speaker, House of Delegates

Joseph M. Beck, II, MD, Little Rock
Chairman of the Council

Established 1890. Owned and edited by the Ar-
kansas Medical Society and published under the di-
rection of the Council.

Advertising Information: Contact Stephanie
Hopkins, P.O. Box 3686, Little Rock, AR 72203;
(501) 372-2816.

Postmaster: Send address changes to: The Joumalof
the Arkansas Medical Society, P. O. Box 55088, Little
Rock, Arkansas 72215-5088.

Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.

The Journal of the Arkansas Medical Society
( ISSN 0004- 1 858) is published monthly by the Arkan-
sas Medical Society, #10 Corporate Hill Drive, Suite
300, Little Rock, Arkansas 72205. Printed by The
Ovid Bell Press, Inc., Fulton, Missouri 65251.
Periodicals postage is paid at Little Rock, Arkansas,
and at additional mailing offices.

330 • The Journal

Volume 97

COMMENTARY

The Gospel According
to 'Calvin and Hobbes'*

Lee Abel, MD

If you can remember being a child, or it you have a child (especially a son),
then you would probably enjoy Bill Watterson’s comic strip “Calvin and
Hobbes.” Though Mr. Watterson has retired, collections of the comic strip are
available as paperback books. For several years, I have kept a couple of “Calvin and
Hobbes” anthologies in my exam rooms. I find it a great pleasure to walk into the exam
room and find my patient grinning from ear to ear or even laughing out loud at some
of Calvin’s antics or Hobbes’ wit. I feel hopeful that even if nothing else happens in the
exam room that day, perhaps the patient’s visit will have been therapeutic.

“Laughter is the best medicine” is a popular aphorism. Humor has long been thought
to promote health. The Bible says, “A merry heart doeth good like a medicine” (Proverbs
17:22). Humor can be used inappropriately or in a hurtful manner, but we have all
experienced its beneficial effects. It can make disappointment and frustration bearable,
and add fun to the mundane. It’s a great stress reducer and can increase optimism. It
can heal wounds that scalpels can’t touch and cause regression of even advanced
hardening of the attitude.

One of my partners loves to laugh. During the workday, I can sometimes get pretty
grim. I’m trying to think hard, or trying hard to think. I’m trying to do the right thing
and worried about doing the wrong thing. I’m trying to remember everything I should,
and wondering if I’m forgetting something. And then I hear my partner’s huge laugh
come rolling down the hall. At least on one occasion years ago, I actually thought,
“What the hell is so funny?” Now I try to use his laugh as a reminder that often I really
could lighten up a bit. The sound of his laughter and the thought of him leaning back
in his chair and having a good laugh with a patient makes me smile.

I learned in medical school and residency that pleasure was obtained in medical
practice solely from “doing a good job,” which involved making the right diagnosis
and giving the right medication. My partner taught me it’s possible to derive pleasure
from just the relationship with the patient. Maybe most doctors figured this out sooner
than I did, but being able to laugh with my patients is something I feel thankful for.

Perhaps my experience is not so unusual. A funny thing happens to most people as
they pass from childhood to adulthood. They laugh less. Perhaps the humor deficit
that arrives with the responsibilities of adulthood is a special challenge for doctors.
How do we deal with frightening and serious problems without becoming always serious?
How do we deal with events of great gravity without becoming too grave? How do we
deal with issues of great importance without succumbing to feelings of self-importance?

I’ve been impressed that the Dalai Lama seems very happy and has a ready laugh,
yet also seems to have a deep awareness of, and empathy for, the suffering of other people.
I have also been intrigued by Jesus’ teaching that to enter the kingdom of heaven we
must become like little children. Perhaps part of what Jesus meant was that it is possible
for even us adults to experience life with a childlike sense of awe, wonder and joy. Digging
for “buried treasure,” Calvin finds “a few dirty rocks, a weird root and some disgusting
grubs” and then enthusiastically proclaims to Hobbes, “there’s treasure everywhere!”
Maybe laughter is not the best medicine, but it’s a very good one. The price is
right. No insurance company (yet) disallows it or requires prior authorization. Perhaps
a lawyer would advise that I add a disclaimer noting that laughter may have side-
effects (laughing so hard it hurts) and may be infectious. Of course, lawyers aren’t
especially known for their sense of humor. Fortunately, a sense of humor can be
cultivated. So if you know any good jokes, please send them in. I’m really serious
about trying to laugh more. ■

*C harks Schultz, the creator of the “Peanuts" comic strip, died last year. One of his
books was titled “The Gospel According to Peanuts.”

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WHAT WE’VE DONE FOR YOU LATELY

Progress on the
Long-Range Plan

By Carlton L. Chambers III, MD

The long-range planning process for the Arkansas Medical Society is
alive and well. The three committees — Governance, Communication
and Membership — are busy with efforts to provide renewed interest
and enthusiasm in our society.

Our effort to respond to the changing professional and economic
environment faced by our young physicians is being balanced with
maintaining what has been good about our organization.

If you were at the last annual meeting, you were apprised of the need to
make some significant changes in how the AMS functions and
communicates with its members. Those of you who attended and
participated so enthusiastically in the early fact-finding planning meetings
enumerated these needs.

As you will recall, one of the greatest obstacles to achieving our goals
as an advocacy organization is effective communication. This was made
astonishingly clear when a survey of long-range planning volunteers proved
that most of them were unaware of many of the activities and efforts of our
Arkansas Medical Society.

While the house of medicine is increasingly influenced by the
participation of physicians in managed-care entities, PHOs, IPAs and other
organizations, we must never forget that we are the house of medicine for
all practitioners. The precept that has governed our lives and actions for
centuries is the ethical obligation to put our patients first.

As the one organization that can and must speak for the needs of our
patients, the Arkansas Medical Society must involve all physicians who are
like-minded in that drive to put the patient first.

Any ideas you have about any of these areas should be communicated
to the committee chairpersons right away. Specifically, we’re looking for
ideas on how can we recruit physicians who are not AMS members, how
we can ensure that all members’ needs and concerns are being met, and
most important, how the AMS can more effectively communicate with the
membership.

The committee chairs are as follows:

Membership: Dr. P. Vasudevan (870) 338-6749
Communication: Dr. Linda McGhee (501) 521-8260
Governance: Dr. Dwight Williams (870) 239-8504
At the annual meeting May 3-5, we will be reviewing the actions of the
committees’ work to date. We will be proposing several changes that will
be important to all of our members and potential members. This is your
opportunity to participate and involve yourself in the process. I urge you to
make every effort to attend this meeting in Hot Springs. ■

Dr. Chambers is the secretary of the AMS , chair of the long-range planning
committee and an otolaryngologist in Little Rock.

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334 • The Journal

Volume 97

Doctors traveled many miles,
taking time out of their busy
schedules, to attend the AMS’
annual “Day at the Capitol”
program.

The activities began with regis-
tration at 11:30 a.m., followed by a
catered lunch at noon at the Arkansas
Education Association Building.
Alter lunch, Zeno gave the guests
an overview of more than 50
health-related hills being debated
during the 83rd General Assem-
bly. Then the guests headed to
the Capitol to visit with their
legislators and to watch the
Legislature in action.

Some of the bills on the
AMS’ radar include three
public health bills pertaining
to cigarette smoking. Zeno
urged Society members to ask their
legislators to oppose these bills.

The first of the bills, House Bill 1250,
introduced by Rep. Dean Elliot, R-Maumelle,
prohibits the Arkansas Department of Health
from regulating or prohibiting smoking in
restaurants with a seating capacity of less than
25, or in any eating establishment where
required modifications (air filtration systems,
etc.) would not be readily achievable.

Zeno said the hill is bad for three obvious
reasons: 1.) It removes the authority to regulate
smoking from the state Department of Health,
the very entity that is in charge of protecting
public health. 2.) It exempts small eating
establishments, which are generally in confined
spaces where patrons and employees are the
most susceptible to the effects of secondhand
smoke. 3.) It gives every eating establishment,
regardless of size, an excuse to ignore any safe
air modifications required by the Health
Department by simply saying that the modifi-
cations are not readily available.

To emphasize the dangers of secondhand

By Shelby Brewer

★ ★★★★★★★★★★★★★★★

Shedding their white coats for a day, doctors
across the state gathered together for a common
purpose — to voice their views. More than 1 00
physicians, spouses, medical students and clinic
managers united at the state Capitol Jan. 31 to
meet with legislators — a process that is
essential in protecting the future of medicine,
said Lynn Zeno, director of governmental
affairs for the Arkansas Medical Society.

★ ★★★★★★★★★★★★★★★

Number 1 0

April 2001 • 335

smoke, Zeno read a letter from an
oncologist about a woman who
worked in a restaurant where smoking
was allowed:

“A 58-year-old white female
worked for the past 25 years in a
small-town cafe. She reports
that nearly everyone at the
cafe smokes, and she serves
meals there six days a week.

In July, she was noted to
have multiple pulmonary
nodules and was found to
have a non-small cell car-
cinoma of the lung. She has
never smoked and does not
live in a house with smokers.

Her only exposure is in her
workplace. She’s received six
months of chemotherapy with
some stabilization of disease.

It’s my opinion that this
cancer was induced by
secondhand smoke.”

Dr. Douglas Snyder, an
anesthesiologist at the
University of Arkansas for
Medical Sciences, agreed
secondhand smoke is a
threat to public health and
that this bill is indeed a step
backward.

“I would like to see
smoking prohibited in public
places, especially restau-
rants, and I certainly agree
that people shouldn’t have to
walk through smoke to
access a hospital,” Snyder
said. “The smoking should be
limited to areas that are
physically removed from the
entrances to the hospital.”

Smoking in hospital
entranceways was also a
topic at the lunch program, and
many doctors expressed their
disapproval of it. But doctors also
acknowledged that a total ban of
smoking in hospitals might cause the
hospitals to lose several good nurses
who smoke.

Dr. Carlton Chambers, an
otolaryngologist for UAMS and sec-
retary of the AMS, was also against
the passage of this bill.

“That should be our most im-
portant activity right now — making
sure this bill doesn’t get passed,” Dr.
Chambers said, “because it will
reduce the effectiveness of the
public Health Department’s action in
curtailing smoking. Basi-
cally, we just need to let
the public Health Depart-
ment do what it does —
regulate the healthy
environment of the
community.”

The second smoking-
related bill, House Bill
1429, introduced by Rep.
Sandra Rodgers, D-Hope,
would repeal Arkansas
Code 22-3-220, which
prohibits smoking in the
state Capitol.

Zeno said that in a
recent special session,
legislators were given
statistics from the U.S. Cen-
ters for Disease Control
and Prevention on smo-
king. Studies show that
smoking kills more Amer-
icans than alcohol, AIDS,
car crashes, illegal drugs,
murders and suicides
combined.

Other statistics men-
tioned were that 5,200
Arkansans die each year
from smoking and that
$600 million in annual
health care expenditures
in Arkansas are directly
related to tobacco use.

Zeno said this bill
should be opposed to
protect the nonsmoking
legislators and other
members of the public from the
damages of secondhand smoke.

“And Arkansas legislators should
serve as role models for all citizens
in the fight against tobacco use,
especially the thousands of young-
sters who tour the state Capitol,” he
said.

The third bill, House Bill 1430,
also introduced by Rodgers, amends
Arkansas Code 6-21-609, which

prohibits smoking or the use of
tobacco products in or on any
property owned or leased by public
school districts.

The obvious reason this bill should
be opposed, Zeno said, is that the
current prohibition on tobacco use on
public school property not only helps
protect our children, but also ensures
that faculty and other school
personnel serve as role models for the
students.

Statistics show that 11,000
Arkansas children under age 18
become new daily smokers each year
and that Arkansas ranks third in the
nation in the number of children who
smoke, Zeno said.

In addition to the smoking
legislation, the Society is also closely
monitoring legislation relating to tort
reform and managed care during the
session.

Making Opinions Heard

Overall, Zeno said the “Day at the
Capitol” event, which began in 1989,
was a success. AMS staff was
especially pleased with the turnout,
which was larger than the Society
staff expected.

“I’m always amazed at how many
physicians — who have in the past
been reluctant to contact their
legislators — realize how easy it is
to talk to legislators after they see
how the legislative process works.”

Several legislators, in turn, said
they were impressed at how well
large associations, such as the
Arkansas Medical Society, commun-
icate their political interests.

“Without question, there is power
in numbers,” said Sen. Jon Fitch, D-
Hindsville, “and the associations get
a lot more credibility because they are
representing a larger group and a
more diverse flow of ideas.”

Fitch said although legislators may
not always agree with the views of
associations, they do put a lot of
confidence in their opinions.

Rep. Marvin Steele, D-West
Memphis, agreed that associations
and grassroots communication are
helpful to legislators. “I use them to

Lynn Zeno

Studies
show that
smoking
kills more
Americans
than
alcohol,
AIDS, car
crashes,
illegal
drugs,
murders
and

suicides

combined.

336 • The Journal

Volume 97

Photo: Mark Wilson

Lynn Zeno speaks
about medical-
related bills at the
afternoon luncheon.

get a lot of information, and I have
found them to be a source of good,
reliable information,” he said. Steele
said the Medical Society, specifically,
has been helpful to him since he’s
the vice chair of the Public Health,
Welfare and Labor committee.
“Anytime I need to know something
about an issue, they’ve gotten me
all the information I’ve needed to
know, whether it was in regards to
an issue they’re for or against.”

Steele offered his thoughts on
House Bill 1250, which prohibits the
state Health Department from
regulating or prohibiting smoking in
restaurants with certain seating or
air filtration system limitations.

“I am in favor of restaurants
providing a nonsmoking area,” he
said, “but I don’t know if I’m willing
to make restaurants completely
smoke free. I think restaurants
should provide areas for both
smokers and nonsmokers, and I
think restaurants should have the
choice.”

Keeping Tabs

Although the three smoking bills
are important issues for the AMS,
there are many others the Society
tracks and alerts members about.

From the beginning of the
legislative session, the Society has
sent weekly bulletins to its
members, highlighting the hot
issues for that week.

Zeno said that as of Feb. 1, 66 of
the 896 bills introduced were
medical-related. Generally, he said,
more than 200 medical-related bills
are introduced by the end of a
session.

At the Society’s 2000 Fall
Meeting in October, Michael E.
Dunn, president of Michael E. Dunn
and Associates Inc., a public affairs
consulting company in Arlington,
Va., reminded physicians that issues
that affect them are often deter-
mined by legislators who have no
background in health care and that
physicians are the most qualified to
convey their needs and the needs
of their patients to
lawmakers.

Zeno agreed with
Dunn’s comments. “The
Medical Society and its
governmental affairs team
have been very successful
in monitoring legislation
and representing the con-
cerns of Arkansas phy-
sicians,” Zeno said. “But
we can’t overestimate how
important it is for our local
physicians to commun-
icate with their local
legislators.”

Wrapping up the day’s
activities, the Society
held an evening re-
ception at the Arkansas
Arts Center to honor the
members of the Legis-
lature. A crowd of more

than 300, including nearly every
legislator from every district,
attended the reception, which Zeno
said was an excellent turnout.

Among some of the legislators
attending were Senate President
Pro Tern Mike Beebe of Searcy and
House Speaker Shane Broadway of
Bryant.

The purpose of the “Day at the
Capitol,” Zeno said, was to give
doctors and others a chance to raise
questions and talk to legislators
about issues that could affect
doctors and, more important, their
patients. After talking with doctors
and legislators, that goal seemed to
be accomplished.

At the end of the day, Drs. Wayne
Brooks and Mitch Singleton
reflected upon the benefits of getting
involved in the legislative process.

Dr. Brooks, a physical medicine
and rehabilitation doctor at
Northwest Medical Center in
Springdale and past president of the
Washington County Medical Society,
said as a whole, physicians are
usually poor at making their voice
heard.

“Even though we have good
lobbyists, as individuals, we don’t
do as good a job, so I think it’s
important that we show up and let
people know we are interested and
that we are looking to see what our
representatives are doing,” he said.

Dr. Singleton, a Fayetteville
ophthalmologist and current
president of the Washington County
Medical Society, advises doctors to
take the first step in becoming
involved in the legislative process —
being an active member of the AMS.

“You’ve got to stand up and be
counted,” he said. “You’ve got to get
involved. We all gripe about what
all the insurance companies, HMOs
and the government regulators are
doing to us, but the only al-
ternative we have is for the AMS
to speak for us. We’re lucky to have
Lynn Zeno and the rest of the staff
to do that. With every issue we
have, they’ve always been very
responsive. They do a good job of
representing us.” ■

Number 10

April 2001 • 337

Meet Our Members

Drs. P. and Kanaka Vasudevan By Shelby Brewer

Although their native
India is far away, the
Vasudevans have made
a home in Helena.

Volume 97

For husband-and-wife team Drs. Parthasarathy Vasudevan, a
urologist, and Kanaka Vasudevan, an anesthesiologist, the
string of events that led them from India to Helena, Ark.,
has made all the difference in their lives.

Dr. P., 62, who was bom in Malaysia and schooled in Madras,
India, prefers that his patients call him by his first initial since
his name is difficult to pronounce. He said it was his wife’s brother
who sparked his interest in moving to the United States.

“Her [Dr. Kanaka] brother was already here, and he was always
telling me about all the good things in America,” Dr. P. said.
“And she was really keen on the idea, so we decided we’d move.”
In 1973, the Vasudevans moved to New York City, where
Dr. P. completed his first year as a surgical resident at Jewish
Memorial Hospital. Soon afterward, the couple moved to Boston,
where they had two sons — Barath, now 26, and Deepu, 24.
Besides taking care of two baby boys, the couple also completed
their residencies and fellowships — Dr. P. in urology and Dr.
Kanaka in anesthesiology — while living in Boston.

Ending up in Helena was a blessing, the
couple say.

After seeing an ad in the Journal
of the American Medical Association
searching for a urologist to move to
Helena, Dr. P. moved his family to
the small town, and immediately
liked what he saw.

“The people were really nice to
me. They picked me up at the airport,
showed me around, and we had all
kinds of funny questions we

asked each other,” he said. “After 23 years of living here, I have
no regrets,” he said.

Today, Drs. P. and Kanaka are settled in Helena and have a
private practice. As a couple, they have several things in common.
Both are from India, both are doctors, and both said they were
influenced to go into their specific fields by fellow Indians.

After attending medical schools in both India and America,
Dr. P. said he had noticed one major difference between them —
testing systems.

“Passing an examination is tough [in India] because we follow
the British system. We don’t have these four' answer, multiple'
choice questions. Everything we answered had to be in essay fomt.”

He said American medical schools are better, however, at
teaching students the practical aspects of medicine rather than
just the theory behind it.

But one thing that stays the same no matter what country
the couple are in is their dedication to their marriage. And perhaps
just as interesting as their voyage to Arkansas is the story behind
their marriage.

“In India, traditionally, we believe in ananged maniages,”
Dr. P. explained. “Their family would contact our family, and then
the parents would decide if there’s a suitable match or not. They’d
compare horoscopes and whatnot, and then we’d get to meet
each other.”

He said that in their case, it was different because her brother
was a good friend of his and he already knew her.

“And since she was in medical school in India and I had
already done mine, we decided we could match.” The couple
were married in 1970.

But both agree that being doctors and trying to balance a
marriage and a family has presented its share of difficulties. Dr. P.
said the toughest obstacle was when they were both doing their
residencies in Boston with two young boys.

“We had to be sure we weren’t both on call at the same time,”
he said. “At night, we used to just exchange kids without seeing
each other. In the morning, she’d leave the children at the baby
sitter’s, and at night, I’d go pick them up because she’d be on call
by then at the hospital.

“But here in Helena, we’ve had some wonderful, wonderful
people who were willing to help us out. It has been a real blessing
for us to move to a small town.”

Although Dr. Kanaka is now the director of
anesthesiology at Helena Regional Medical Center,

her earlier days as an anesthesiologist
weren’t so easy.

When she started treating patients
at the hospital in the 70s, she debated
with other physicians on staff about the
use of cyclopropane, a highly flammable
gas that was once used as an anesthetic to
put pregnant mothers to sleep before
delivery hut is now banned.

If it weren’t for the encouragement
of Dr. Richard Clark, a professor at the
University of Arkansas for Medical
Sciences in Little Rock, Dr. Kanaka said
she would have quit working at the
hospital. Dr. Clark, who is now retired, sent
a letter to the chief of staff at the hospital,
explaining that cyclopropane is not in use
anymore and that the gas, along with the
canister, is even used as an antique to show
students.

After that, Dr. Kanaka said the
doctors apologized, hut they couldn’t
offer her a job. “I asked for $30,000 and
they couldn’t pay that. But that was a
good thing for me because I went into
my own practice, and it gave me a lot of
confidence,” she said.

Dr. Kanaka said upgrading the
department of anesthesia to what it is
today is one of her greatest achievements.
“Before, they didn’t have good equipment
and they didn’t have the daigs we wanted.
Today, it has much higher standards and
quality.”

Dr. R has had his own hurdles to jump
as well, but the biggest challenge he faces
as a doctor in the Delta, he said, is figuring
out how to take care of the indigent
population.

He said that he takes care of the
indigent in his office at no charge
whenever possible. But when these patients
need attention at the hospital, he said, it’s
more difficult.

He estimated that 10 percent of the
Helena area’s population is indigent.

“We have a good number of them in
the Delta, and most doctors here have to
take care of them. ”

Dr. P. said he is very happy that they
moved to a small town, mainly because
it has allowed him to become involved in
the community, which is what he loves
the most.

He is the president and founding
member of the Phillips County Com-
munity Foundation and Delta Health
Alliance, chairman of the membership
committee of the Helena Chamber of
Commerce, and assistant district governor
of the Rotary Club. He’s also very involved
with the Arkansas Medical Society,
serving as the membership committee
chairman. When he’s not busy
volunteering, Dr. P. likes to garden, swim,
listen to classical Indian music and watch
C-SPAN.

Dr. Kanaka is also involved in the
Medical Society as well as the Arkansas
Society of Anesthesiologists. In her spare
time, she likes to listen to music, surf the
Internet and experiment with digital
photography.

The Vasudevans joined the Arkansas
Medical Society in 1978, and both agreed
that it has been a blessing.

“Any time I have any problems, all I
have to do is pick up the phone and call
them, and they’ll help us out,” Dr. P. said.
“Without the society, it seems like it would
he very difficult to survive.” ■

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Number 1 0

April 2001 • 339

LOSS PREVENTION

The Same
Again and

J. Kelley Avery, MD

Lesson

Again

An excision
biopsy
showed
adenocar-
cinoma, with
normal
nodes.
Because of
the clinical
findings and
the tissue
analysis of
the tumor, a
modified
radical
mastectomy
was done,
and at least
two of the
removed
nodes were
positive for
tumor.

Case Report

A 3 7 'year-old woman, gravida 2, para 2, with
one living child had a regular examination every
year at her local health department (HD). She
was a moderate smoker and used birth-control
pills (BCPs) for contraception.

Five years before her death, she had a routine
examination at the HD, where the examining
nurse felt some “nodular thickening” in the left
breast. The nurse strongly recommended a
mammogram and cautioned the patient about the
risks of taking BCPs and smoking. The patient
was asked to consider other contraceptive methods
and was urged to stop smoking, but she stated that
the pill was the only method she was willing to
use at that time, and was given a supply of them.

Five weeks later, the mammogram was done,
and the mammographer reported fibronodular
tissue in both breasts. There were calcifications
in the left breast that appeared to be benign, but
there was no indication of malignancy. No return
date was suggested, and no repeat mammogram
was advised.

The report of the mammogram was sent to
the HD, where the physician saw the report and
documented that he wished to see and examine
the patient in two weeks.

On examination, the HD physician
considered that a malignancy could not be ruled
out and documented a “possible lump, left breast.”
The nurse called the patient and left a message
on the answering machine for the patient to call,
but she did not.

Three months later, the patient returned to
the HD for her routine annual examination by
the nurse practitioner and was scheduled to
return to see the physician.

Following this visit, the physician made an
appointment for the patient to see a general
surgeon. He stated in his referral note, “She has
a small lump just above the nipple and the
mammogram shows a benign-appearing
calcification in the left breast, but I felt that she
ought to have it checked.” The HD physician

drew a diagram of the mass he felt and made it a
part of the consultation request. She received
only one month of BCPs, and was told that she
would have to see the consultant before she got
any more.

When she did not keep the appointment, it
was rescheduled, and again she was informed that
no further services would be given by the HD
until she saw the surgeon and he evaluated her
breast.

Nine months after the initial report, the
patient was evaluated by the general surgeon,
who reported that neither his examination nor
the mammogram found any evidence of
malignancy.

“1 am not planning to see her again unless
she develops future problems.” he wrote. “I
recommend that she have a follow-up
mammogram in two years.” The HD physician
recorded that the consultant saw no need for
biopsy at that time.

About a year later, the patient reported to
the HD for her usual examination with the
statement that she had a white discharge from
both breasts. There were two lumps said to be at
the 10 and 11 o’clock positions. She said that
the lumps seemed bigger but that she was being
followed by the consultant and was supposed to
see him “next summer.”

She was told that no further BCPs could be
given, since she was a smoker and needed a
follow-up mammogram. The examination was
done with the finding of a large 5-by-4'Cm
irregular lesion, which the mammographer
strongly suggested be biopsied.

An excision biopsy showed adenocarcinoma,
with normal nodes. Because of the clinical
findings and the tissue analysis of the tumor, a
modified radical mastectomy was done, and at
least two of the removed nodes were positive for
tumor. The patient chose a different surgeon from
the first consultant.

Her recovery from surgery was uneventful.
The final diagnosis was a Stage 2 carcinoma of

340 • The Journal

Volume 97

the breast with two of nine removed
nodes positive for cancer. Chemotherapy
was begun. Scanning technology was
used to determine the absence of brain,
bone, or liver/spleen metastasis.

She was followed closely by the
oncologist, and chemotherapy ended
about three years after the initial
mammogram. At that time she appeared
to be cancer-free and was excited about
her plans to pursue a nursing education.

Sixteen months later, she was
admitted to the hospital because of a very
heavy menstrual period. She had lost
weight and was obviously anemic. A
thorough workup revealed metastatic
disease involving the chest (pleura with
effusion), bone, and soft tissues of the
abdomen. She was in renal failure due to
bilateral ureteral obstruction, for which
stents were placed.

The kidney problem cleared, and the
oncologist continued to follow this
patient closely. She was aggressively
treated with chemotherapy, required
repeated hospitalizations for compli-
cations of her disease and her treatment,
and died about seven years after the first
suspicious mammogram.

A lawsuit was filed two years before
her death, charging all concerned with
her treatment with negligence in the
failure to diagnose and treat cancer of the
breast in a timely fashion. Early in the
litigation, the HD physician and the
hospital were dismissed from the case.
The patient died while the case was being
developed for trial.

Loss Prevention Comments

It is apparent that this patient could
be seen as contributing to her own
problems. She was noncompliant with
instructions to get the mammogram in
the first place. She was slow to get to the
first surgical consultant for the first
examination, and she did not return at
all after the HD doctor suggested that he
should re-evaluate her. She continued to
insist on oral contraception after having
been told time and time again to stop
smoking because the combination of
BCPs and smoking was dangerous. She
was a noncompliant patient.

In evaluating a case of this sort, it
must be remembered that the arena of

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April 2001 • 341

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medical malpractice is not a scientific
arena. The issues embodied in the case
must be evaluated from a lay jury’s
perspective. The last thing to which such
a jury would be sympathetic would be
for the defense attorney to try to assess
liability to this dead woman.

The surgical consultant saw this
patient nine months after the suspicious
mammogram. Experts believe that he
should have repeated the test. Although
the consultant did not feel the mass,
other examiners, both the nurse and the
HD physician, had felt it, and since the
evaluation of a small lesion in a nodular
breast is difficult, the mammogram
should have been repeated.

Experts further agree that in all
probability, the 1-cm lesion had not yet
spread. The initial mammogram that
described the nodular breast and the
“benign-appearing calcification in the left
breast” also stated that “neoplasm cannot
be ruled out.” In this situation, the
mammogram should have been repeated,
and if the findings were still equivocal, a
biopsy was indicated at that time.

As the preparation for trial
proceeded, the plaintiff took the
deposition of the patient, who was
desperately ill. Since it was also thought
that “a day in the life of’ videotape was
planned for the trial, the defendant
physician requested that the case be
settled. A negotiated settlement of a
moderate six-figure amount, which
included more in treatment costs than
in paid loss, was achieved.

Again and again we have described
cases of this type that have consistently
strongly indicated the necessity of a
breast biopsy when, after mammo-
graphy and careful physical exam-
ination, there remains even a suspicion
of neoplasm. ■

Reprinted from an October 1 999 issue
of Tennessee Medicine. The Case of the
Month is taken from actual Tennessee
closed claims. An attempt is made to
fictionalize the material in order to make it
less easy to identify. If you recognize your
own case, please be assured that it is
presented solely for the purpose of
emphasizing the issues presented.

342 • The Journal

Volume 97

CARDIOLOGY

Thoracic Aortic Aneurysm Revisited

Venkatarama Gaddam, MD — Asem Rimawi, MD — John Mckee, MD
Editor: Eugene Smith III, MD

Aortic aneurysm is the
13th most common cause of
death in the United States.

The incidence of this di-
sease is estimated to be 5.9
cases per 100,000 person-
years. Aortic aneurysms are
best described as a perm-
anent, localized progressive
dilatation of the aorta
having a diameter of at
least 1.5 times that of the
expected normal diameter
of a given segment. We
describe a case of aortic
dissection to highlight the
difficulties in diagnosis and
management of thoracic
aortic aneurysms.

Case No 1 :

An 81 -year-old male
presented to the emergency
department with complaints of chest pressure starting one hour
before arrival. He described the pressure to be deep in his chest,
almost at the back. His past medical history was significant for
colon cancer.

He was noted to have low blood pressure with systolic
blood pressure between 80-90 mm Hg and a heart rate of 90/
min. He had ST depression on the electrocardiogram in the
inferior leads, for which he was diagnosed with unstable angina
and treated with aspirin, intravenous heparin, intravenous
metoprolol and intravenous morphine for pain control.

Because of the presence of persistent ST depression and chest
pressure, the patient was taken to the catheterization laboratory
for left heart catheterization. His left coronary arterial system
was normal. Due to the inability to engage the right coronary
artery, an aortic root injection was performed, which revealed a

Type 1 thoracic aortic
aneurysm (TAA) that
extended to the abdominal
aorta distal to the renal
arteries (Figure 1). The
patient was immediately
mshed to the operating room
for repair. He died during
surgery due to profound left
ventricular dysfunction.

Case No 2:

A 65 -year-old man was
admitted for treatment of
ventricular tachycardia caus-
ing dizziness. He had a bi-
cuspid aortic valve that was
replaced in 1993. He was
noted to have poststenotic
aortic root dilatation of 4 cm.
His aneurysm progressed from
6.3 cm to 9 cm within the last
5 years (Figure 2). Though
surgical correction was offered, he preferred a conservative
approach toward management of this aneurysm. He agreed for
surgery in October 2000 and had aortic root and valve replacement.
He was discharged home on the eighth postoperation day.

Discussion

The incidence of this disease is estimated to be 5.9 cases per
100,000 person-years. The mean age at the time of diagnosis
ranges between 59 and 69 years, with men predominating over
women with a ratio of 2: 1 to 4: 1 . TAAs have a variety of causes,
including atherosclerosis, cystic medial degeneration,
myxomatous degeneration due to Marfan’s syndrome, infection,
trauma, poststenotic dilatation and syphilitic aortitis. Forty
percent of patients are diagnosed incidentally on routine imaging
studies.

Figure 1: Aortic root angiogram showing the small true lumen (thin
white arrow), large false lumen (blocked white arrow). The false
lumen extends into the right inominate artery (black arrow).

Number 1 0

April 2001 • 343

Figure 2: Para-sternal long axis view of echocardiogram showing massive aortic root
aneurysm (A), Left ventricle (LV), left atrium (LA), and right ventricle (RV).

Chest pain and pressure are the most
common presenting symptoms. It can also
cause cough and dyspnea from
tracheobronchial obstmction, hoarseness
due to pressure on the recurrent laryngeal
nerve, dysphagia secondary to esophageal
narrowing, or superior vena-caval
syndrome. TAA can cause aortic regurgi-
tation, due to aortic root and annular
dilatation that leads to congestive heart
failure. Narrowing of the coronary ostia
by enlarged sinuses of Valsalva can cause
ischemia or infarction. The most
worrisome consequences are of rupture
or dissection of the aneurysm. Rupture
into trachea can cause hemoptysis and
rupture into the GI tract can produce
hematochezia (aorto-esophageal fistula).

Many TAAs are brought to clinical
attention by chest X-ray done for other
purpose. Angiography is the gold
standard with 90% sensitivity and 95%
specificity. Transesophageal echocardi-
ography, computerized tomography, or
magnetic resonance imaging with
gadolinium and angiography are
commonly used for accurate character-
ization of the aneurysm. Ultrason-
ography, though very useful for AAA
(abdominal aortic aneurysm), is not so in
case of TAA. Intravascular ultrason-
ography is an emerging new technology
that provides exceptionally high
resolution images of the aneurysm.

The natural history of TAA is quite

diverse, reflecting a broad spectrum of
etiologies. Much of the available evi-
dence on growth rates and risk factors
derives from studies of AAA. Such risk
factors include size, hypertension,
smoking, syphilis and arteriosclerosis.
Aneurysms are classified based on the
position (Figure 3).

Treatment

All aneurysms are potentially fatal
with unpredictable rates of expansion and

rupture. Beta-blockers have been shown
to reduce the pulsatile force on the aortic
wall, by reducing the blood pressure, thus
reducing the size and progression of the
aneurysm. Though propranolol has been
used in trials, other heta-blockers can be
assumed to have the same effect.

In acute dissection, agents with fast
onset of action and short half-life should
be used, as they stabilize the dissection
and prevent rupture. (See Table 1 )

Surgical Management

Most vascular surgeons currently
recommend surgery for:

• asymptomatic aneurysms 5 cm or
larger

• symptomatic, including Aortic
regurgitation, CHF

• acute dissection involving the
ascending aorta

While more aggressive management
of smaller aneurysms (4-5 cm) has been
recommended by some, others have
suggested that asymptomatic, slow-
growing aneurysms under 6 cm can be
successfully followed by serial CT scans.
All decisions are individualized to each

Figure 3

The Two Most Widely Used Classifications of Aortic Dissection

The DeBakey classification includes three types. In type I, the intimal tear usually originates
in the proximal ascending aorta and involves the ascending aorta, the arch and variable
lengths of the descending and abdominal aorta. In type II, the dissection is confined to the
ascending aorta. In type III, the dissection may be confined to the descending thoracic aorta
(type Ilia) or may extend into the abdominal aorta and iliac arteries (type lllb). The dissection
may extend proximally to involve the arch and the ascending aorta. The Stanford classification
has two types. Type A includes all cases in which the ascending aorta is involved by the
dissection, with or without involvement of the arch or the descending aorta. Type B includes
cases in which the descending thoracic aorta is involved, with or without proximal (retrograde)
or distal (antero-grade) extension. (Reprinted with permission.)5

Debakey Classification

Type I Type II Type I

Stanford Classification

Type A Type B

patient.

The most common modality of
surgical repair is replacement of the
ascending aorta and the aortic valve with
a composite graft containing a Dacron
graft and mechanical valve prosthesis,

344 • The Journal

Volume 97

Table 1

Monitoring

Blood pressure
Cardiac rhythm

Possibly with pulmonary artery catheterization

Beta blockade
(should be used even if
the blood pressure is
normal)

Esmolol IV: 500 mug/kg/min for 1 min, then 50
mug/kg/min for 4 minutes, then maintenance
infusion of 10-50 mug/kg/min
Labetalol: 20 mg IV over 2 minutes, repeat every 1 0-
20 minutes up to 300 mg
Propranolol: 1-2 mg IV every 4-6 hours

Pain control

Preferable IV medications, e.g. morphine, meperidine

Blood-pressure control
(Goal is mean blood
pressure 60-70 mm Hg)

Sodium nitroprusside — start at 0.3 mg/kg/min IV

Alternatives: Intravenous calcium channel blockers /
angiotensin converting enzyme inhibitors

Hypotension

Titrate anti-hypertensive management, if not tolerated can
use neo-synephrine

with implantation of the coronary
arteries in the Dacron graft. Aortic
allografts are also used when preserving
the native valves is possible.

Mortality depends on the etiology of
the aneurysm, but varies between 0% to
6%, with 5-year survival 60%-90% and
a 10-year survival of 50% to 70%.

Conclusion

Due to the potentially fatal compli-

cation, high index of suspicion for aneur-
ysm needs to be maintained when patients
present with atypical chest pain. Beta-
blockers should be started even if the
blood pressure is normal. Diagnosis should
be made using any one of the available
modalities. Prompt surgery with repair of
the dissection can save lives. Asympto-
matic aneurysms with size less than 4 cm
need close follow up with CT scan every
6 months. ■

Drs . Goddam, Rimawi and Mckee are with
the department of cardiology at the University of
Arkansas for Medical Sciences. Dr. Smith is with
the division of cardiology, DAMS Medical
Center and John L. McClellan Memorial
Veterans Hospital in Little Rock.

References:

1 . Fuster V. Medical treatment of the
aorta. Cardiol Clin 1999. 17(4): 697-
715, viii

2. Leach SD, Toole AL, et al. Effect of
beta-adrenergic blockade on the
growth rate of abdominal aortic aneur-
ysms. Arch Surg 1988. 123:606-609.

3. Shores, J, Berger K, et al. Progression
of aortic dilatation and the benefit
of long term beta blockade in
Marfan’s syndrome. N Engl J Med
1994. 330:1335-1341.

4. Coady MA. Natural history,
pathogenesis, and etiology of thoracic
aortic aneurysms and dissections.

Cardiol Clin 1999. 17(4): 615-35.

5. Kouchoukos NT, Dougenis D. Surgery
of the thoracic aorta. N Engl J Med
1997.336:1876-88.

UAMS

Office of Continuing Medical Education...

Committed to Life-Long Learning

2001 Programs

i - •

Apr. 5-7 Symposium on Critical Care and Emergency Medicine

Location: Arlington Resort Hotel, Hot Springs, AR
Joint Sponsors: UAMS and Univ. of Tennessee

Apr. 25 Best Practices in the Continuum of Care

Location: DoubleTree Hotel, Little Rock, AR
May 5 W.W. Stead Chest Symposium

Location: The Austin Hotel, Hot Springs, AR
May 11 The Diamond Conference

Location: The Riverfront Hilton Inn, North Little Rock, AR
May 19 The Diabetes Update 2001

Location: The Holiday Inn Select, Little Rock, AR
June 1-3 23rd Annual Family Practice Intensive Review

Location: UAMS Education II Building, Little Rock, AR

For additional information,

call the Office of Continuing Medical Education at (501 ) 661-7962
or check out our website, www.uams.edu/cmefd/cme2.htm

Primary Care
Practice Opportunity

Number 1 0

April 2001 • 345

Use of Diffusion-Weighted Images

AUTHORS: Scott M. Schlesinger, MD; Alonzo R. Burba, MD

EDITOR AND AUTHOR: Steven R. Nokes, MD

History

A 34-year-old man presented with a low-grade fever
and new onset seizures. An MR scan was performed (Figures

1-4).

Findings

The precontrast gradient T weighted image (Figure 1)

reveals a low-signal lobular mass with a high-signal capsule
and surrounding vasogenic edema in the right temporal lobe,
with mild compression of the cerebral peduncle. Following
contrast administration (Figure 2), irregular rim en-
hancement occurs. The T, weighted image (Figure 3)
demonstrates loss of signal (dark) in the capsule due to

Figure 1 . Gradient T, (TR 225 TE 4.2) weighted axial image of the brain.

Figure 2. Post contrast T, weighted (500/1 1 ) image.

346 • The Journal

Volume 97

Figure 3. T2 weighted (4000/86 ef) fast spin echo. Figure 4. Diffusion-weighted image.

paramagnetic effects. The center of the abscess is
inhomogeneous. The vasogenic edema is best appreciated on
this sequence as bright. On diffusion-weighted images (DWI)
(Figure 4), the central abscess cavity is very bright and the
vasogenic edema is almost imperceptible.

Diagnosis: Brain abscess

Discussion

Brain abscesses are potentially fatal lesions. The mortality
has decreased from approximately 40% to less than 5% since
the advent of CT. CT and MR both reveal ring-enhancing lesions
in cases of intracranial abscess. This is a nonspecific finding also
seen in primary brain tumors, metastases, resolving hematomas,
infarcts and, occasionally, demyelinating disease.

MR typically reveals a thin low signal rim on long TR/TE
images and high signal rim on short TR/TE images, which is
helpful in suggesting the diagnosis. This is due to paramagnetic
effects from hydroxyl radicals in macrophages in the collagenous
capsule.

More recently, diffusion-weighted images have become
available on most MR scanners. These images are usually
obtained to look for acute infarcts but have been found to be
useful in distinguishing abscesses from necrotic tumors. Image
contrast on DWI is based on microscopic motion of water
molecules. Normally, this motion is random (Brownian motion).

A process, which restricts free water motion, will appear

bright on trace DWI images. In cerebral infarcts, cytotoxic edema
is bright due to swollen cells reducing the translational motion
of extracellular water. In abscesses, the central cavity contains a
complex mixture of proteins, inflammatory cells, cellular debris
and bacteria. The water molecules in this environment are bound
to various macromolecules restricting Brownian motion and
resulting in increased signal on DWI. The central cavity of necrotic
tumors is a much more homogeneous environment and is usually
low signal or DWI. Diffusion imaging usually requires strong echo-
planar gradients, which are becoming commonplace on high-field-
strength magnets. H

Dr. Nokes is with Radiobgy Consultants of Little Rock. Dr.
Schlesinger is affiliated with St. Vincent Infirmary Medical Center in
Little Rock, and Dr. Burba is in private practice in Little Rock.

References:

1 . Castillo M, Mukherji SK. Diffusion-weighted imaging in the
evaluation of intracranial lesions. Sem in US, CT and MRI
2000;21:405-416.

2. Desprechins B, Stadnik T, Koerts G, Shabana W, Breucq C,
Osteaux M. Use of diffusion-weighted MR imaging in
differential diagnosis between intracerebral necrotic tumors
and cerebral abscesses. AJNR 1999; 20: 1252-1257.

3. Haimes AB, Zimmerman RD, Morgello S, Weingarten K,
Becker RD, Jennis R, Deck MDF. MR imaging of brain
abscesses. AJNR 1989; 10: 279-291.

Number 10

April 2001 • 347

• t a* nT(fftc.€L ujaSuf#

.. , r... «.**» ■ x.^x.

i: lie rcfc o n ^Til^IMhS
ivirir.nu.lu.'ifuvnP
i%A\ u.-fi’u

^-isw

AMS BENEFITS, INC.

M.Jr/

A wholly owned subsidiary of the
Arkansas Medical Society
P.O. Box 55088

Little Rock, Arkansas 72215-5088
(501)224-8967
WATS 1-800-542-1058
FAX (501) 224-6489
“Available products include group
health, office package, professional
liability, home, auto, and more.”

U A L I T Y

Arkansas Foundation
for Medical Care

Arkansas Patient Safety Initiative

EDITORIAL PANEL: WILLIAM E. GOLDEN, MD; DEBORAH L MARPLE, RN, BS, CPHQ;

DONNA S. WEST, PHD

The Arkansas Foundation for Medical Care is developing quality improvement projects geared to patient safety, such as studying issues
involved with appropriate dosing for pediatric and geriatric patients.

BY WILLIAM E. GOLDEN, MD

Dne year after
the release of
the ground-
breaking Institute of
Medicine report “To
Err is Human:
Building a Safer
Health System,” state health care
leaders have joined forces to
enhance patient safety in Arkansas.

The Arkansas Patient Safety
Initiative (APSI) is the effort of the
major statewide health care
organizations in Arkansas that came
together after the Institute of
Medicine reported that as many as
98,000 patients die each year in the
United States as a result of medical
errors.

Providing health care is a very
complex business. A single patient in
the hospital for three to five days

probably received hundreds of
services provided by thousands of
interactions with, and “handoffs” to,
numerous health professionals
ranging from physicians to nurses to
X-ray technicians to transport aides.
Even with an accuracy rate of 99.9%,
there would be one error for every
1,000 handoffs in a hospital setting.
The average patient most likely has a
few thousand handoffs during a
typical hospital stay.

Arkansas Foundation for Medical Care (AFMC) is the Peer Review and Quality Improvement Organization for Medicare
and Medicaid in Arkansas. AFMC works collaboratively with providers, community groups and other stakeholders to
promote the quality of care in Arkansas through evaluation and education. For more information about AFMC quality
improvement projects, call 800-272-5528, ext. 204.

Number 10

April 2001 • 349

U A L I T Y

Many experts believe that the
key to ensuring patient safety is
preventing medical errors from
occurring in the first place. Most
safety risks do not result from
individual carelessness, but rather
can he attributed to limitations in
processes an organization has put in
place. The risks to patient safety are
manageable when effective systems
are in place to ensure safety. This
alliance of leaders can work closely
with their respective constituents
and members to promote improved
systems.

What
can and
should be
done to
reduce
medical
errors in
our health
care
system?
Some
solutions
lie in better
education,
reminder
systems and
safeguards.
Other solutions lie in better
information technology that works
to assist caregivers at the point of
service in monitoring and
controlling processes employed on
behalf of a patient.

Members of the Arkansas
Patient Safety Initiative believe that
much can be done to enhance the
patient-care environment through
cause analysis and sharing of best
practices. Mandatory reporting
systems, by definition, bring about
defensiveness and concerns over the
use of the quantitative data.
Moreover, voluntary systems of
environmental assessment and
quality improvement, when
matched with a regional collabor-
ative educational framework, can
achieve as much, if not more, than

the mere counting of events. It is
the goal of APSI to monitor the
trends in research in patient safety
and facilitate its dissemination and
local adoption and adaptation in
Arkansas and thus benefit all
patients and facilities in our
community.

Members of APSI are free to
pursue their own initiatives for their
members and constituencies in
patient safety. APSI will serve as a
clearinghouse to promote the
activities of its members and to
share new information on this
important topic. In addition, there
will be periodic joint initiatives to
promote the core concepts in
patient safety.

This March, APSI sponsored its
first statewide conference on patient
safety and featured local and
national speakers with experience in
focused initiatives to enhance the
patient-care environment. Issues
included pediatric sedation, the
ethics of error disclosure, common
errors in prescription writing and
broad national overviews from Dr.
Steven Small of the University of
Chicago Patient Safety Center and
Mary Foley, president of the
American Nursing Association.
Clinical staff leaders from
Washington Regional Medical
Center in Fayetteville and Baptist
Medical Center in Little Rock
discussed processes and programs at
their facilities to address patient
safety and medical error. APSI plans
to offer additional seminars and
training in root cause analysis as this
effort unfolds.

In addition to such public
forums, the Arkansas Foundation for
Medical Care is developing quality
improvement projects geared to
patient safety. For example, it will be
looking at issues involved with
appropriate dosing for pediatric and
geriatric patients as well as the
appropriate use of perioperative
antibiotics to avoid postoperative

wound infections. Appropriate timing
of perioperative antibiotics can reduce
wound infection by more than 80%.
Nevertheless, there is frequently up to a
20% failure rate to deliver antibiotics
within a two-hour time window before
the first surgical incision.

Use of systems interventions such
as checklists or procedures to ensure
documentation and execution of core
critical health processes can go a long
way toward supplementing
professional education and enhancing
vigilance.

Improving patient safety requires
freedom to report errors and an
educational environment to address
core issues responsible for their
genesis. A shared bad experience at
one institution can create
opportunity for the health
professional community and its
facilities to avoid similar episodes in
its own local environment. The APSI
aims to change the climate by
creating an educational, nonpunitive
forum in which questions and critical
events can be discussed openly so that
solutions can be implemented.

The APSI gives Arkansas
providers the opportunity to discuss
potential and past safety issues openly
in hopes of finding solutions and
improving care. The Arkansas health
care community believes that its
patients deserve focused attention on
patient safety and, through
collaborative planning and
communication, can provide the
opportunity and forum for
constructive dialogue and
information dissemination to
facilitate adoption of new measures to
make health care more effective in
our communities.

Will error go away completely?
Probably not. Health care is a very
personal, tailored and resource-
intensive undertaking. Can the
health care system do a better job?
Absolutely. It just takes the
commitment, the data, the leadership
and innovation to make it happen. ■

Arkansas
Patient __
Safety
Initiative

350 • The Journal

Volume 97

SPECIAL ARTICLE

Pediatric Injuries Resulting from Use
of All-Terrain Vehicles

Daniel Lance Bercher, M.Ed., B.S., NREMT-P — Kelly Staley, MD — Lori W. Turner, Ph.D., R.D. — Mary Aitken, MD

Emergency medical services transported 319 patients under 20 as the result of an ATV-
related injury over a two-year period, from

Abstract

Annually, 20,000 children are
injured while operating all-terrain
vehicles (ATVs).

The purpose of this paper was to
review child- ATV injuries in Arkansas
and identify any areas in need of further
investigation. An analysis of emergency-
medical-service transports was done for
children 0-19 years who had ATV-related
injuries in Arkansas from 1998 to 1999.
Prehospital-reported child-ATV emer-
gencies were identified, separated by
county, and emergency encounter rates
were calculated. Our results indicate that
emergency medical services (EMS)
transported 319 children in Arkansas
from 1998 to 1999. ATV injury
information is limited in Arkansas, but
available data indicate high injury rates
existed for many rural counties.

Introduction

In 1997, an estimated 20,000
children were injured while operating
or riding an all-terrain vehicle (ATV).1
Even after efforts were made by the U.S.
Consumer Product Safety Commission
(CPSC) in 1988 to limit ATV
manufacturer and sales practices, the rate
of child-related injuries on ATVs has
been unchanged.1 At least 90% of
children injured on ATVs were operating
vehicles rated for an adult size.2

Characteristics of ATVs

An ATV is a three- or four-wheeled
motorized vehicle powered by a
gasoline engine smaller in size and
weight than most road-licensed
vehicles. The tires are designed for
gripping rough terrain and are not likely
to skid on paved surfaces. The engine
displacement for ATVs ranges from 50-
500 cm.3 They can weigh up to 600

pounds and reach speeds up to 60 mph.
ATVs are designed for use by a single
rider. Although the seat appears large
enough to accommodate multiple
riders, it is actually intended for one
person. Riders can shift, adjust and
balance their weight distribution in
rough terrain situations.

All-terrain vehicles have been
manufactured since 1971. The sales of
ATVs skyrocketed in the 1980s. With
the increasing use of ATVs came an
equally escalating morbidity and
mortality due to injuries. From 1983 to
1986, there was a 300% increase in
emergency department treatment for
ATV-related injuries.3

As a response to this realization, the

1998-1999.

CPSC became involved and helped ban
the production of three-wheelers
through 1988. In addition, the CPSC
entered into a 10-year binding consent
decree that involved improved warning
labels, restrictions of the sales of adult-
size ATVs for use by children less than
1 6, industry voluntary standards for safer
vehicles and implementation of a
nationwide training program.

A one-time registration fee must be
paid to the Department of Finance, but
no driver’s license is required under
existing Arkansas law. Children over 12
can legally operate ATVs on their own.
Children under 12 can operate ATVs
with adult supervision. Operation of
ATVs on public highways is unlawful,

Number 1 0

April 2001 • 351

but riders are allowed to cross highways
to get to another field.

A national survey of ATV operators
revealed that 25% of the drivers engaged
in difficult maneuvers such as doing
wheelies.4 More than half (53.7%)
admitted that they were carrying
passengers. Only 1 1 % had ever taken a
formal ATV driving course, and 32%
admitted that they never wore a helmet.

Mechanism of Injury
and Mortality

The CPSC reported that the two
most frequently reported hazard patterns
associated with ATV-related deaths
were collisions (56%) and overturns
(35%).' More than halt of all collisions
occurred with a stationary object, while
35% occurred with another motorized
vehicle. An additional 11% of the
collisions involved another person or
an animal. Overturns were usually the
result of the operator losing control or
they occurred while riding up or down
a hill. Backward overturns were more
common than forward overturns. Sixty
percent of the deaths occurred on
roadways and 29% occurred on paved
roads. Only 1% of the deaths occurred
on actual ATV trails.

Even though three-wheeled ATVs
have not been manufactured since
1988, they still account for 25% of all
ATV-related injuries.2 These ATVs
were regarded highly dangerous
secondary to their high center of gravity
and front-wheel brakes that predispose
the vehicles to rollovers, flipping
backward and instability in negotiating
turns. Three-wheel ATVs are two-and-
a half to three times more likely to
cause injury than four-wheel ATVs.

Risk Factors

Two important risk factors are
large engine size and male operators.
Increasing engine size appears to
correspond to increasing probability of
injury. Engines greater than 200 cc’s
contribute to 83% of the ATV injuries.2

Populations at Risk

Similar to other high risk-taking
behaviors, the population of males under

16 is vastly overrepresented in the ATV
injury pool. In addition, male drivers
are three times more likely to
experience injury. Furthermore, this
effect decreases with age.

Children constitute 14% of all ATV
drivers but are responsible for a
staggering 40% of all injuries. In-
terestingly, this ratio of injuries has
remained fairly stable since 1985.1

Purpose

The purpose of this report was to
explore pediatric injuries related to all-
terrain vehicles in Arkansas. A second
objective was to identify areas worthy
of further investigation.

Methods

The Arkansas Department of Health
Division of Emergency Medical Services
and Trauma Systems (DEMS) has
implemented a statewide data program
that includes every emergency run that
prehospital-care providers must complete
when a patient has been encountered.
The data system includes information
such as patient age, nature of the
emergency, and location. An analysis was
completed using all encounter forms
datedjan. 1, 1998, and Dec. 31, 1999, for
patients aged 0 to 19, with “all-terrain
vehicle” reported as the nature of the
emergency. All emographic, emergency
care, helmet use and related injury data
were tabulated. In addition, the location
of the emergency medical services (EMS)
encounter was defined as the county
where the emergency scene was reported.

An estimate of the rate of ATV-
related injury in Arkansas children was
calculated using the EMS data and
county-specific 1990 census data. The
counties in west, northwest and north-
central Arkansas were classified as
mountainous; the central counties were
classified as varied; and southern and
eastern counties were designated flat.

Results

The available data indicated that
Arkansas EMS transported a total of
319 patients under 20 as the result of
an ATV-related injury over the two-
year period. Males accounted for 65.2%

of all the patients. Only 6% of patients
reported wearing a helmet. Seventy-
seven percent of the children were
under 16. The most common location
was reported as “other traffic way”
(which is defined as any other road than
a highway with speeds at or above 55
mph) in 37.6% of the cases. A residence
was reported to be the second most
common location, at 16.3%. Patient
ejections were reported in 10% of the
cases, while rollovers were reported
8.8% of the time.

Although Van Buren County had
the highest child- ATV EMS encounter
rate, at 255 per 100,000, the actual
population of the county ranked 48th
among the 75 Arkansas counties. Van
Buren County also had a mountainous
terrain classification (See Table).
Pulaski County, on the other hand, had
an ATV-child EMS encounter rate of
11 per 100,000, which ranked 66th.
Pulaski is the most populous county in
the state (See Table).

Discussion

The purpose of this article was to
explore pediatric injuries related to all-
terrain vehicles in Arkansas based on
prehospital emergency encounter
reports. Several patterns emerge from
these EMS data. Seven of the top 10
child-ATV-rated counties were in the
mountainous terrain of the north and
northwest regions of the state. For
example, Madison County in northwest
Arkansas had the fifth highest ATV-
child EMS encounter rate. Madison
County was only ranked 56th by
population (See Table).

Among Arkansas’ three most
populous counties — Pulaski,
Washington and Sebastian — the ATV-
child EMS encounter rates were
markedly lower, with rankings of 66th,
58th and 65th respectively (See Table).
The available evidence suggests that
higher EMS encounter rates with child-
ATV incidents occur in less populous,
mountainous counties.

Since Arkansas, like many states,
does not track all emergency
department admissions, it is not known
how many patients were actually treated

352 • The journal

Volume 97

Arkansas Prehospital-Reported ATV Emergency Encounters for 1998-1999

(for Children 0-19 among the 75 counties)

ATV Injury
Rank

Arkansas

County

ATV Injury
Rate per 100,000

Total #
Injured

General Terrain
Classification

Total Population
0-19 years

Population

Rank

Van Buren

255

Mountainous

14,008

Cleburne

237

Mountainous

19,411

Fulton

211

Mountainous

10,037

Clark

209

Flat

21,437

Madison

161

Mountainous

11,618

Lafayette

150

Flat

9,643

Perry

149

Mountainous

7,969

Clay

144

Flat

18,107

Newton

140

Mountainous

7,666

Polk

135

Mountainous

17,347

Pulaski

Varied

349,660

Washington

Mountainous

113,409

Sebastian

Mountainous

99,590

secondary to an injury received as the
result of ATV operation. Furthermore,
since the majority of ATV accidents
occur in rural settings, it is highly likely
that some individuals choose not to
wait for emergency medical services due
to extended ambulance response times.
The actual number of EMS transports
very likely underrepresents the grand
total number of ATV'child-- associated
injuries. Unfortunately, the degree of this
underrepresentation is unknown.

A second objective of this study was
to identify areas worthy of further
investigation. The actual number of
children injured while riding ATVs in
Arkansas is not known, and further
information about the degree of exposure
of this population would be helpful in
targeting interventions. Further, the
development of a comprehensive trauma
system that tracks all patients could
facilitate an assessment for the potential
impact of injury prevention programs.
Since the likelihood of such a
comprehensive program being
implemented any time soon is doubtful,
individual case studies and assessments at
the county level for child- ATV injuries
could shed some light on this issue.

The fact that higher rates of EMS
encounters occurred in the rural counties
suggests that there may be a large

population of young people who are riding
ATVs unsupervised in the pastures and
backwoods of the state. More public
education and ATV awareness programs
may be warranted, especially for counties
with high child- ATV EMS encounter rates.

The American Association of
Pediatrics (AAP) recommends that
ATV operation should be limited to
children and adults who are old enough
(at least 16 years old) to legally operate
an automobile.5 Arkansas state law, in
contrast, allows children 12 years and
older to operate ATVs with no adult
supervision. Wider dissemination of the
AAP recommendations and implemen-
tation of the guidelines could form the
foundation of broader prevention pro-
grams for the state.

Although the actual health care costs
and number of debilitating incidents
associated with child- ATV injuries are
unknown, it appears that many children
in the state are at risk for ATV injury.
Comprehensive educational efforts and
the consideration of aggressive, regulatory
interventions for ATV use, especially in
young children, may reduce the number
of these preventable injuries. ■

Dr. Bercher is interim chairman of the
department of emergency medical sciences
at the University of Arkansas for Medical

Sciences. Dr. Staley is a physician at the

Conway Children’s Clinic. Dr. Turner is

assistant professor of health sciences at the

University of Arkansas in Fayetteville. Dr.

Aitken is assistant professor of pediatrics at

Arkansas Children’s Hospital.

References

1. U.S. Consumer Product Safety
Commission, Washington, D.C:
Notice, Federal Register 63(174).
Sept. 9, 1998.

2. U.S. Consumer Product Safety
Commission. National Electronic
Injury Surveillance System.
Washington, D.C: US Consumer
Product Safety Commission; 1994-
1996.

3. U.S. Consumer Product Safety
Commission. Annual Report of ATV
Deaths and Injuries. Washington,
D.C: U.S. Consumer Product Safety
Commission; Aug. 30, 1999.

4. Rodgers GB. Part I, Report on 1997
ATV Exposure Survey. Bethesda,
MD: U.S. Consumer Product Safety
Commission, 1998.

5. American Academy of Pediatrics,
Committee on Injury and Poison
Prevention. All-Terrain Vehicle
Injury Prevention: Two-, Three-, and
Four-Wheeled Unlicensed Motor
Vehicles. Pediatrics 2000; 105: 1352-
1354.

Number 1 0

April 2001 • 353

PEOPLE + EVENTS

HONORED

Physicians Receive
Awards from AMA

Each month the Amerh
can Medical Association
presents the Physician’s
Recognition Award to those
who have completed accep-
table programs of continuing
education.

AMA recipients for
December are Dr. Jerry A.
Alexiou of Little Rock, Dr.
Peggy J. Brown of Searcy
and Dr. Ivory A. Kinslow of
El Dorado.

OBITUARIES

Frederick C. Turner, MD

Dr. Frederick C. Turner,
58, died Nov. 28, 2000. He
was a resident of Mountain
Home and practiced at Pigeon
Creek Medical Center. Dr.
Turner graduated in 1968 from
the University of Texas
Medical Branch, Galveston.
He is survived by his wife.

Rolland F. Broach, MD

Dr. Rolland F. Broach, 80,
of Little Rock died Dec. 27,
2000. He was a 1945 graduate

of the University of Arkansas
for Medical Sciences and was
a practicing psychiatrist in
Searcy.

He is survived hy two
sons, Mark Broach and Greg
Broach, both of Little Rock; a
daughter, Cathy Broach of
Kansas City, Mo., three
grandchildren; and one great-
grandchild.

Robert Edwin Elliott, MD

Dr. Robert Edwin Elliott,
60, of Searcy died Jan. 13. Dr.
Elliott was a partner in the
Arkansas Radiology Group,

P.A., in Searcy, a graduate of
the University of Arkansas
for Medical Sciences and a
member of Trinity Episcopal
Cathedral.

He is preceded in death
by his mother, Gordie Lee
Bethea Elliott. He is survived
by his wife, Marilyn Pauli
Elliott; a son, Mark Elliott of
Searcy; a daughter, Leigh
Ann Bennett of Little Rock;
his father, Ed Elliott of
Searcy; a brother, Hollis
Elliott of Tuckerman; a sister
Ann Dunham of Normal, 111.;
and a granddaughter. ■

New Members

Robert M. Jarvis, MD

Specialty: Resident-P

58 Warwick Road
Little Rock, AR 72205
(501) 224-5262

Sandra Johnson, MD

Specialty: D

4301 W. Markham St., #576
Little Rock, AR 72205
(501) 686-5110

Karla R. Jones, MD

Specialty: Resident-FP

4010 Mulberry St.

Pine Bluff, AR 71603
(870) 541-6010

Amir L. Kellow, MD

Specialty: Resident- AN
4301 W. Markham St., #515
Little Rock, AR 72205
(501)686-6114

Delaney L. Kinchen, MD

Specialty: Resident-EM
5901 JFK Blvd., #4302
North Little Rock, AR 72116

Kevin R. Koehler, MD

Specialty: Resident-FP
460 W. Oak St.

El Dorado, AR 71730
(870) 862-2489

Richard E. Kremp, MD

Specialty: R

500 S. University Ave., # 108
Little Rock, AR 72205
(501)664-3914

Gregory Laffoon, MD

Specialty: GS
1900 Malvern Ave.

Hot Springs, AR 71901
(501) 624-5700

Debra C. Lawrence, MD

Specialty: OBG

525 Western Ave., #205
Conway, AR 72032
(501) 450-3920

George S. Lawrence, MD

Specialty: FP

630 Burnett

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Rachel J. Lehmkuhl, MD

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Fangru Lian, MD

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Mark Elwood Linskey, MD

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Ellen Lu, MD

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Little Rock, AR 72205
(501)686-6560

Nicholas P. Luzietti, MD

Specialty: OBG

101 Skyline Drive
Russellville, AR 72081
(501) 890-7125

George J. Madera, MD

Specialty: CD

1609 W. 40th St., #201
Pine Bluff, AR 71603
(870) 536-3015

Mustafa Mahdavy, MD

Specialty: Resident-PTH

4301 W. Markham St.

Little Rock, AR 72227
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Michael J. Mancino, MD

Specialty: Resident-P

4301 W. Markham St., #589
Little Rock, AR 72205
(501)686-5483

Brett H. May, MD

Specialty: GS
505 Hospital Drive
Mountain Home, AR 72653
(870) 425-9120

Brian P. McAndrew, MD

Specialty: PS

10809 Executive Center
Drive, #100
Little Rock, AR 72211
(501) 227-0707

Emily M. McNellis, MD

Specialty: Resident-PD

800 Marshall St.

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Jason A. Merrick, MD

Specialty: Resident-FP

4010 Mulberry St.

Pine Bluff, AR 71603
(870) 541-6000

354 • The Journal

Volume 97

Toni L. Middleton, MD

Specialty: FP

1400 W. 43rd St.

Pine Bluff, AR 71603
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Mashhud Munir Mirza, MD

Specialty: NEP

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Little Rock, AR 72227
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Justin E. Morgan, MD

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Little Rock, AR 72211

Mark Moss, MD

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Little Rock, AR 72207

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521 S. Elm St., #530
Little Rock, AR 72205
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John R. Nolen, MD

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612 S. 12th St.

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Eduardo R. Ochoa Jr., MD

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Lila Pappas, MD

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Paul J. Parcon, MD

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Paige M. Partridge, MD

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Number 1 0

April 2001 • 357

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Arkansas Financial Group Inc., The 334

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Arkansas Managed Care Organization 356

Asti, William Henry, AIA 331

Central Arkansas Radiation Therapy Institute 342

Central Flying Service 341

Chenal Properties 332

Farmers Insurance Group 355

GuestHouse Inn 331

Health Data Services, LLC 333

Jefferson Regional Medical Center 345

Maggio Law Firm 334

Mary Healey’s Fine Jewelry 330

Metropolitan National Bank 355

Micheal Munson, A.G. Edwards <Sc Sons Inc 327

Online Technologies Inc 358

Professionals Advocate Inside front cover

Pro Travel 330

Regions Bank 358

Residence Inn 333

Riverside Motors 339

State Volunteer Mutural Insurance Co Back cover

University of Arkansas for Medical Sciences 341

University of Arkansas for Medical Sciences

Continuing Education 345

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Marketing Assistant
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358 • The Journal

Volume 97

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364 • The Journal

Volume 97

COMMUNICATIONS COORDINATOR

Judy Hicks

EXECUTIVE VICE PRESIDENT

Kenneth LaMastus, CAE

ASSISTANT EXECUTIVE VICE PRESIDENT

David Wroten

EDITORIAL BOARD

Sue Chambers, MD
Joseph M. Beck, II, MD
Lee Abel, MD
Samuel Landrum, MD
Jerry Kendall, MD
William Ackerman, MD

Pediatrics
Oncology
Internal Medicine
Surgery
Family Practice
Anesthesiology

EDITOR EMERITUS

Alfred Kahn Jr., MD

ARKANSAS MEDICAL SOCIETY
2000-2001 OFFICERS

Gerald A. Stolz, Jr., MD, Russellville
President

Joe Stallings, MD, Jonesboro
President-elect

Paul A. Wallick, MD, Monticello
Vice President

Lloyd G. Langston, MD, Pine Bluff
Immediate Past President

CarltonL. Chambers, III, MD, Harrison/Little Rock
Secretary

Dwight M. Williams, MD, Paragould
Treasurer

Anna Redman, MD, Pine Bluff
Speaker, House of Delegates

Kevin Beavers, MD, Russellville
Vice Speaker, House of Delegates

Joseph M. Beck, II, MD, Little Rock
Chairman of the Council

Established 1890. Owned and edited by the Ar-
kansas Medical Society and published under the di-
rection of the Council.

Advertising Information: Contact Stephanie
Hopkins, P.O. Box 3686, Little Rock, AR 72203;
(501) 372-2816.

Postmaster: Send address changes to: The Journal of
the Arkansas Medical Society, P. O. Box 55088, Little
Rock, Arkansas 72215-5088.

Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.

The Journal of the Arkansas Medical Society
( ISSN 0004-1 858 ) is published monthly by the Arkan-
sas Medical Society, #10 Corporate Hill Drive, Suite
300, Little Rock, Arkansas 72205. Printed by The
Ovid Bell Press, Inc., Fulton, Missouri 65251.
Periodicals postage is paid at Little Rock, Arkansas,
and at additional mailing offices.

Articles and advertisements published in The Jour-
nal are for the interest of its readers and do not
represent the official position or endorsement of The
Journal or the Arkansas Medical Society. The Journal
reserves the right to make the final decision on all
content and advertisements.

Volume 97 Number 11
May 2001

OF THE ARKANSAS MEDICAL SOCIETY

Winner of the ASAE Excellence in Communications Award

CONTENTS

2001 BUSINESS REPORTS

367 Executive Vice President

368 AMS Council

373 Nominating Committee
375 AMS Budget

377 Long Range Planning Committee

Medical Education Foundation for Arkansas

379 Arkansas State Medical Board

383 AMS Benefits

384 AMS Medical Student Section

385 Arkansas Health Care Access Foundation

386 Arkansas Medical Foundation

387 Arkansas Department of Health

389 Pulaski County Medical Society

Continuing Medical Education Accreditation Committee

DEPARTMENTS

366 What We’ve Done for You Lately
391 People + Events

393 Arkansas Retreats

394 Index to Advertisers

Number 11

May 2001 • 365

WHAT WE’VE DONE FOR YOU LATELY

Hear

From

You!

You can now e-mail AMS
at the

following addresses:

Main address:

ams @ arkmed.org
Ken LaMastus:
klamastus @ arkmed.org
Lynn Zeno:
zeno @ arkmed.org
David Wroten:
dwroten @ arkmed.org
Kay Waldo:
kwaldo @ arkmed.org
Journal:

journal @ arkmed.org

Plus. . .

Visit our web site at:

www.arkmed.org

AMS Supports Ban on
Smoking in Restaurants

By David Wroten

For the last three months, the focus of activity has been at the state Capitol.
However, on Thursday, March 15, a lesson in democracy took place in
the State Health Department auditorium, where the public spoke out on
the proposed ban on smoking in restaurants. Dr. William N. Jones of Little
Rock was there to speak for the Arkansas Medical Society.

After two hours of testimony, the count was clear — 25 spoke in favor of
the ban, six against. Speaking against the regulation were representatives of the
restaurant industry and individual restaurant owners. Speaking for the regulation
were grandmothers, a young mother and her infant child, several physicians, an
extraordinary number of teen-agers, people whose lives have been impacted by
smoking and exposure to second-hand smoke, and YES, even a couple of
restaurant owners.

Near the end of the hearing a young man, probably no more than 16 years
old, was able to summarize all of the comments he had heard into three words ...
rights, money and health.

The restaurant owners spoke of their right to run their businesses the way
they wish without government interference and the right of consumers to choose
their restaurant. The proponents of the regulation spoke of rights as well —
their right to enjoy a meal without smoke blowing in their face, the rights of
restaurant employees to work in a smoke-free environment, and the rights of
infants and children, who have no choice where their parents take them to eat.

The restaurant owners also talked about money and the financial impact
the regulation would have on their business. They assume, of course, that smokers
will stay home and no longer eat at restaurants if smoking is banned. However,
there are studies on this issue that show that business and profits have actually
increased in places where similar regulations have been enacted.

Everyone talked about health. It was clear to anyone listening that health is
the overriding issue in this discussion. It trumps both the “rights” issue and the
“money” issue. When one chooses to operate a restaurant, they do so knowing
that their rights end where the public’s health begins. The public expects and
demands that health officials regulate eating establishments to protect the safety
of the food. Tobacco smoke in those restaurants is no less a threat.

While we may have the option of sitting in “non-smoking” sections, we
usually must travel through the smoking section to get there, or even worse, the
non-smoking area is separated only by a half-wall or screen. And what of the
restaurant employees, particularly the wait staff? How many other employees in
America are expected to breathe second-hand smoke while performing their
job?

Surely we have reached a point in our understanding of the health
consequences of tobacco smoke where the outcome of this issue should be crystal
clear. A total ban on smoking in restaurants is the right thing to do.

And for one last reality check. If a smoker can sit through an entire Razorback
football or basketball game without a smoke, surely they can last long enough
for my children to finish their meal. ■

366 • The Journal

Volume 97

Report of the Executive Vice President

By Ken LaMastus, CAE

The AMS
was

responsible
for a

regulation
passed by
the

Arkansas
Insurance
Department
that will
help

physicians
with slow
payments
by

insurance
companies
and some
third-party
payers.

We won the tobacco settlement battle
— well maybe. After the Arkansas
House of Representatives failed to
pass the CHART plan in the special legislative
session last year, Gov. Mike Huckabee referred
the issue to the people through an initiated act
with the help of several groups, including the
Arkansas Medical Society, which provided more
than $50,000 for the effort.

The people of Arkansas voted over-
whelmingly (64%) to approve the plan, but it
may not be over with yet. The tobacco money
must be appropriated through the Arkansas
General Assembly, and there seems to be some
disagreement in the House.

The AMS’s goal was to see that the
recommendations of the Centers for Disease
Control and Prevention’s for tobacco prevention,
control and cessation were adequately funded and
to further expand Medicaid to the uninsured.
These issues are drawing a great deal of interest,
and the question is, “Will the Arkansas General
Assembly appropriate the money as voted on by
the people of the state or will a portion of this
money be used for other purposes?” If all the
tobacco money is used for health care, then
Arkansas will be the only state in the union to
use 100% of its money on health.

The AMS was responsible for a regulation
passed by the Arkansas Insurance Department
that will help physicians with slow payments by
insurance companies and some third-party payers.

David Wroten has worked with the Arkansas
Workers’ Compensation Commission to help
improve their fee schedule. Some time ago, the
commission recommended their fee schedule be
the same as the Medicare Fee Schedule. The AMS,
along with physicians and their staff from across
the state, were successful in getting this
recommendation overruled. Part of the agreement
was that the Workers’ Compensation Commission
would update their fee schedules periodically.

Dr. Carlton Chambers, who has chaired the
AMS’s Long Range Planning Committee, has
received a lot of help from physicians from across
the state to determine ways the Society can be
more responsive and helpful. Work in this area
is continuing, and we anticipate that
recommendations from the three Long Range
Ad Hoc Committees (Governance, Member-

ship, and Communication) will be presented to
the House of Delegates at the AMS’s annual
meeting in May.

Some of the recommendations from the Long
Range Planning groups have been put in place.
Continuing medical education is now offered
online to AMS members at a 10% discount, and a
bulletin board for the exchange of information
between members is available. We ask that you
view our Web site, www.arkmed.org.

The AMS has joined the Arkansas Founda-
tion for Medical Care and several health-related
associations and licensing hoards to form the
Arkansas Patient Safety Initiative. This resulted
from a very scathing report by the Institute of
Medicine concerning mistakes made in medicine.
Efforts are being made to determine system changes
that could prevent some of the problems now
occurring.

The AMS also continues to offer low-cost
seminars to physicians and their staff on important
issues. The Second Edition of the Physician’s Legal
Guide — a must for any medical office — is avail-
able at the AMS office.

We may have a chance of passing some form
of the patient protection legislation in Congress.
If a reasonable act can be passed, it would remove
the ERISA liability exemption and make health
plans and insurance companies responsible for
their actions the same way doctors and any other
form of business is responsible.

An issue that has been on the horizon but has
not reached the critical stage in Arkansas is the
cost of malpractice insurance. Many states have
already faced significant increases. Back in the
1970s, physicians could pass the cost of malpractice
insurance on to their patients. With price controls
that now exist with Medicare, Medicaid, Workers’
Compensation and managed care, it would be
virtually impossible for physicians to recoup these
increased costs.

The Arkansas State Board of Health recently
established regulations to forbid smoking in eating
establishments. This has been a goal of the AMS,
and we should thank the members of the State Board
of Health for their work.

Thanks to our members and staff who continue
to work on issues, regulations and legislation of
concern to Arkansas physicians and the people they
serve. ■

Number 1 1

May 2001 • 367

Report of the Council

The Council of the Arkansas Medical Society

met on May 6, 2000; Aug. 2, 2000; Oct. 29, 2000; and

Jan. 31, 2001 . A brief summary of actions taken follows:

May 6, 2000

1. David Wroten gave an update on the Arkansas
Department of Human Services contract with Arkansas
Behavioral Care to provide mental health services to
Medicaid patients.

2. Wroten reported that the Arkansas Medical Society
would be meeting with representatives of the Arkansas
Hospital Association, Arkansas Pharmacy Association,
Arkansas Nurses Association, Arkansas Foundation for
Medical Care, Arkansas State Medical Board and other
organizations to discuss voluntary efforts to reduce
medical errors.

3 . An update on the Workers’ Compensation Fee Schedule
was provided hy Wroten. The Arkansas Workers’
Compensation Commission has increased the fee
schedule by 10%.

4- Ken LaMastus encouraged the Council to comply with
Medicaid’s request to use electronic fund transfers for
reimbursement.

5. Dr. Carlton Chambers reported that the AMS had
received a four-year re-recognition from the
Accreditation Council for Continuing Medical
Education. As a recognized accrediting agency, the AMS
recognizes institutions in Arkansas to offer educational
programs and provide CME credit.

6. Lynn Zeno provided an update on the tobacco settlement
negotiations. Upon motion, the Council approved
$25,000 of reserves be used as an initial step to support
the initiated act process and review the process as it
progresses.

7. The Council approved requests for dues exemption.

8. The following committee appointments were approved
hy the Council:

• Budget Committee: Brenda Powell, MD, Hot Springs

• Journal Editorial Board: Reappoint Samuel Landrum,
MD, Fort Smith, representing general surgery; Joseph
Beck, MD, Little Rock, representing oncology; William
Ackerman, MD, Little Rock, representing
anesthesiology

• Medical Education Foundation for Arkansas:

Reappoint Martin Eisele, MD, Hot Springs, President

• Pension Plan Committee: Reappoint John Wilson, MD,
Little Rock; Reappoint Samuel Welch, MD, Little Rock

• Arkansas Medical Foundation: Position #1: Jerry
Stringfellow, MD, Texarkana

• Young Physicians Task Force: Kimberly Garner, MD,
Pine Bluff, Chairman

• Medical Student Councilor: Erik Shultz, Little Rock

9. The Membership Report, Budget Report and MEFFA
audit were presented for information.

10. The AMS Audit was presented by LaMastus. Upon
motion, the Council voted to accept the audit.

11. Dr. J.R. Baker discussed the Arkansas State Medical
Board’s proposed regulation relating to alcohol and
mind altering substances in the actively treating
physician.

12. Dr. Harold Wilson discussed an issue with Medicaid
and fetal non-stress test. Wroten reported a meeting
has been set with the Arkansas Department of Human
Services to discuss this issue. The Council directed
Wroten to continue discussions with the Arkansas
Department of Human Services on these issues.

13. Dr. Jan Turley discussed a recent situation where he
had been asked to sign a background verification
disclosure and agree to allow a detective agency to
investigate his background for a hospital staff
application. Upon motion, the Council directed this
issue be referred to the Executive Committee for review.

14- Dr. Richard Corlin, AM A Speaker of the House of
Delegates, greeted the Council. Dr. Corlin also
expressed his concern of the issue regarding an agency
investigating a physician’s background.

Aug. 2, 2000

1. Zeno gave an update on federal and state legislative
issues.

2. Wroten reported on July 11, 2000, the Arkansas
Insurance Department assumed control of American
Investors Life Insurance Co. AMS Benefits Inc. is
working with clinics insured hy American Investors to
find other coverage.

3. Wroten also reported on the proposal sent to the
Arkansas Insurance Commissioner for a prompt
payment regulation.

4. LaMastus reported the AMS would he working with
Helus/Intel to provide education on Internet
technology. LaMastus also reported plans to improve
and update the Society’s Weh page.

5. Dr. Scott Claycomb of Warren was approved to fill the
vacancy in the Fifth Councilor District.

6. A financial report of the 2000 annual meeting was
submitted for information. The AMS will return to the
Embassy Suites in 2002.

7. Wroten distributed a listing of delinquent and non-
members to Council members. He urged them to con-
tact those listed to encourage membership in the AMS.

8. Dr. Carlton Chambers distributed a list of members for
three new committees established as a result of the long-

368 • The Journal

Volume 97

range planning meetings. The
three committees will address
membership, governance, and
communication issues.

9. Dr. William Jones discussed the
recent issue addressed at the
Arkansas State Board of Health
meeting regarding a smoking ban
in restaurants.

10. Dr. John Burge reported on the
June 2000 AMA meeting. Dr.
Michael Moody reported there is a
movement under way to redesign
the organizational structure of the
AMA, allowing for more specialty
representation which may diminish
state representation.

Oct. 29, 2000

1. John Meador, co-chairman of the
Arkansas Conflict Resolution
Association Speakers Committee,
discussed the association’s activities.

2. Dr. Dwight Williams, chairman of
the Ad Hoc Committee on
Governance, reported on the Oct.
29, 2000, meeting. The committee
discussed the structure of the
Executive Committee, publishing
meeting dates, and how the
Nominating Committee members
are selected and how it functions.
The committee plans to review the
House of Delegates, how it
functions, how it is representative
of membership, and if it should
continue. They will also discuss how
Council members are elected and a
name change for the Council.

Dr. Parthasarathy Vasudevan,
chairman of the Ad Hoc Committee on
membership, reported the committee
had met and would be working to find
methods to regain lost members and
strengthen physician- to-physician
contact. The committee also plans to
research easy payment plans for dues.

Dr. Linda McGhee, chairman of the
Ad Hoc Committee on com-
munication, reported the committee
reviewed the AMS News Brief and The
Journal of the Arkansas Medical Society.
They discussed the Weh site and will
research the possibility of a members-
only bulletin hoard, more use of e-mail
and a section for resident and student
members.

3. LaMastus discussed a proposed
amendment to the AMS 40 IK
Plan that would allow using for-
feitures to reduce the employer’s
contribution. Upon motion, the
Council approved the amendment.

4. Wroten reported AMS Benefits
Inc. is continuing its work to move
clinics insured through American
Investors to other carriers.

5. The Council approved Dr. Sue
Chambers of Little Rock to fill the
pediatric position on The Journal
Editorial Board effective Jan. 1,
2001 . Dr. Jerry Byrum has resigned
as of year-end 2000.

6. Dr. Carlton Chambers recognized
Dr. Steve Strode for his out-
standing work on the AMS CME
Accreditation Committee.

7. Zeno gave an update on the to-
bacco settlement for Arkansas. Dr.
William Jones encouraged the
Council to ask the Arkansas State
Board of Health to enact a total
ban on smoking in restaurants.

8. The membership report was
presented for information.

Jan. 31, 2001

1. Dr. John Burge reported on the
AMA Interim Meeting held in
Orlando, Lla., Dec. 3-6, 2000.
Upon motion, the Council ap-
proved a letter be written to the
congressional delegation ex-
pressing concern about possible
profiteering and the shortage of
the flu vaccine. Dr. Moody sug-
gested a letter also be sent to the
Senate Aging Committee.

2. Dr. Dwight Williams gave a report
on the Ad Hoc Committee on
Governance. The Governance
Committee plans to propose a new
framework of governance that will
include renaming the Council the
Board of Directors.

3. Dr. Gerald Stolz, President of the
Arkansas Medical Society, pre-
sented a plaque to Dr. I. Dodd
Wilson for his service as Dean of
the University of Arkansas Col-
lege of Medicine.

4. Dr. Parthasarathy Vasudevan
reported the Ad Hoc Committee
on Membership has met several

times and has also suggested that
regional meetings be held
throughout the state and include
social functions inviting non-
members and spouses.

5. The Coalition for a Healthier
Arkansas Today (CHART) has
requested $2,500 from the
Arkansas Medical Society to help
with the legal fees in defending
the Initiative Act Campaign in
getting the CHART plan placed
on the November 2000 General
Election ballot. Upon motion,
the Council approved the
expense.

6. LaMastus reported on a recent
meeting of the Ad Hoc Com-
mittee to establish minimum
standards necessary for doctor/
patient contact before a physician
can prescribe medication. The
committee has made a recom-
mendation to the Arkansas State
Medical Board that physicians
should not practice medicine or
prescribe unless a physician/pa-
tient relationship has been
established.

7. LaMastus reported the AMS
ended the year 2000 with income
of approximately $124,000. This
was $24,500 better than budgeted.
The Arkansas Medical Society
Building ended the year with a
$17,000 profit.

8. Dr. James Kolb, Chairman of the
Annual Session Committee,
updated the Council on the plans
for the Arkansas Medical Society
annual meeting to be held May 4-
5 at the Arlington Hotel in Hot
Springs.

9. LaMastus informed the Council
that work is under way to redesign
the AMS Web site. This will
include adding a “members-only”
section.

10. Wroten updated the Council on
HIPAA.

1 1 . Wroten reported the AMS and
Medicaid have been discussing a
modest increase in physician fees.
Wroten provided information to
the Council on this proposal and
asked for feedback within the next
week.

Number 1 1

May 2001 • 369

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The one thing missing

The Executive Committee of the
Arkansas Medical Society met on

May 24, 2000; June 28, 2000; Aug.
23, 2000; Sept. 27, 2000; and Dec.
21, 2000. A brief summary of
actions taken follows:

May 24, 2000

1. Dr. William Stumer, medical ex-
aminer for the state of Arkansas,
met with the Executive Commit-
tee concerning proposed legisla-
tion pertaining to the Medical
Examiner’s Office.

2. The Executive Committee
discussed the Arkansas State
Medical Board’s proposed regu-
lation pertaining to the use of
alcohol and mind altering drugs
while a physician is on call.

3. Dr. Carlton Chambers discussed
the Long Range Planning Com-
mittee.

4. Wroten gave an update on the
tobacco settlement negotiations.

5. Wroten reported on problems
with American Investors Life
Insurance Co. This is the com-
pany that provides insurance
coverage for our group plan.

6. The Executive Committee ap-
proved a list of physicians who
have requested direct member-
ship in the AMS.

June 28, 2000

1. Zeno gave an update on the
tobacco settlement.

2. The Executive Committee dis-
cussed the Nathan Davis Award
Dinner to he held in Washington,

D.C.

3. Spike Dietrich, a representative
from Helus, explained the
computer systems they are
installing in northwest Arkansas.
Helus has asked the AMS to
endorse their system.

4. Dates and accommodations for
future Arkansas Medical Society
meetings were discussed. The
Arlington Hotel is the only hotel
available that is large enough to
accommodate the AMS annual
meeting next year.

5. The Executive Committee ap-

370 • The Journal

Volume 97

proved requests for direct and
emeritus membership.

Aug. 23, 2000

1. The Executive Committee dis-
cussed a survey from the AMA
concerning their Commission on
Unity.

2. Wroten gave an update on the to-
bacco settlement. Another $25,000
request from the governor has been
approved for use in getting the
initiative on the November ballot.

3. Wroten discussed the Arkansas
Insurance Department’s regulation
on prompt payment.

4. The Executive Committee dis-
cussed a letter concerning moving
a monument from Mac Arthur Park
to the University of Arkansas for
Medical Sciences campus.

5. The Executive Committee ap-
proved requests for emeritus and
direct memberships in the AMS.

6. The Executive Committee re-
viewed a press release regarding
John P. Shock, MD, being
appointed interim dean of the
University of Arkansas College of
Medicine. The Executive Com-
mittee suggested that Dr. Shock be
invited to attend Council meetings.

Sept. 27, 2000

1. Kay Waldo reported to the
Executive Committee information
about the cost and requirements
hotels are placing on those doing
convention business with them.

2 . Wroten discussed quality of health
care issues comparing Arkansas to
other states.

3. Wroten reported on a recent
meeting with the dean of the
School of Nursing at UAMS.

4- The Executive Committee re-
viewed the Arkansas State Medical
Board’s proposed regulation
regarding standards for prescribing
legend medication.

5. The Executive Committee also
reviewed the Arkansas State
Medical Board’s proposed reg-
ulation pertaining to licensure of
physicians from other states and
Canada.

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6. LaMastus presented a one-page
summary of additions and de-
ductions from AMS reserves over
the last few years.

7. The Executive Committee ap-
proved a list of physicians
requesting direct membership in
the AMS.

8. The Executive Committee reco-
mmended a letter be written to
compliment Dr. Charles Kemp for
his contribution not only in medi-
cine, hut also to his community at
large.

9. The Executive Committee re-
viewed updated information on the
marker in MacArthur Park and
suggested the dean at UAMS be
contacted for his thoughts as to
where the marker should be
relocated.

Dec. 21 , 2000

1. LaMastus indicated he had sent
out a memorandum last Friday
asking members of the Council if
they had any interest in being
nominated for the Emerging
Leaders Development Program to
he held in conjunction with the
AMA’s National Leadership
Conference. The Executive
Committee suggested that Dr.
Hugh Jackson be recommended
for the Emerging Leaders De-
velopment Program.

2. Dr. Carlton Chambers mentioned
his concern regarding the efforts
that the medical examiner is making
in trying to get support for their
legislation in January. The Exe-
cutive Committee suggested the
AMS staff make contact to quietly
express our concern with the
legislation.

3. LaMastus discussed a letter he had
received from the Arkansas State
Medical Board requesting the
AMS meet with their attorney to
help draft legislation to establish
minimum standards necessary for
a physician/patient contact before
a physician prescribes medication.
The Executive Committee au-
thorized AMS staff to attend these
meetings. ■

372 • The Journal

Volume 97

Report of the Nominating Committe

By Anthony Hui, MD, Chairman

The members of the 2000/2001 Nominating
Committee are Drs. Leonus Shedd; J.R. Baker; Marion
McDaniel; David Jacks; Donya Watson; Michael Young;
Timothy Webb; Timothy Waack; C. Reid Henry Jr.,
secretary; and Anthony Hui, chairman. The Nominating
Committee would like to present to the Society the
following nominees:

President-elect: Carlton Chambers, MD, Little Rock
Vice President: Reappoint Paul Wallick, MD, Monticello
Treasurer: Reappoint Dwight Williams, MD, Paragould
Secretary: Brenda Powell, MD, Hot Springs
Vice Speaker of the House: James Wharton, MD,
Springdale

Delegate to the AMA: Reappoint Larry Lawson, MD,
Paragould

Alternate Delegate to the AMA: Reappoint Michael
Moody, MD, Salem

District Councilors:

District 1: Reappoint Scott Ferguson, MD, West Memphis
District 2: William Waldrip, MD, Batesville
District 3: Reappoint Dennis Yelvington, MD, Stuttgart
District 4: Reappoint John Lytle, MD, Pine Bluff
District 5: Reappoint William Dedman, MD, Camden
District 6: Reappoint Michael Young, MD, Prescott
District 8: Appoint David Bourne, MD, Little Rock;
appoint Stephen Magie, MD, Little Rock; reappoint
Joseph Beck, MD, Little Rock; reappoint C. Reid Henry
Jr., MD, Little Rock; reappoint Anthony Johnson, MD,
Little Rock; reappoint Samuel Welch, MD, Little Rock
District 9: Reappoint Anthony Hui, MD, Fayetteville;
reappoint Jan Turley, MD, Rogers
District 10: Reappoint Robert Sanders, DO, Fort Smith;
reappoint Mike Berumen, MD, Fort Smith
Medical Student Councilor: Dwight Johnson, Little
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“Available products include group
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Cash Budget Report

Arkansas Medical Society

INCOME

Dues $696,053

Journal and Directory $11,000

Booth $25,000

Annual Session $32,000

AMA Reimbursement $9,100

Label and Miscellaneous $7,400

Interest Income $87,000

Specialty Desk $9,020

Continuing Medical Education $13,000

Allocation of G.A. Department $5,000

Educational Programs $45,000

Legal Guide $2,000

TOTAL $941,573

EXPENSE

Salaries $322,293

Travel and Convention $40,000

AMA Delegation $30,000

President's Account $5,000

Taxes $31,000

Retirement $37,700

Stationery and Printing $1 8,000

Office Supplies and Expenses $37,000

Telephone $10,000

Rent $54,672

Postage and Communications $25,000

Insurance & Bonds $58,000

Auditing $5,275

Council and Executive Committee $4,000

Journal and Directory Expense $1 2,000

Dues and Subscriptions $8,000

Gifts and Contributions $2,500

Alliance $8,700

Legal Services (retainer) $27,450

Committee/District Meeting/LRP $5,000

Public Relations $3,000

Miscellaneous Expenses $5,000

Office Equipment & Furniture $9,000

Continuing Medical Education $12,000

Contract Labor $5,000

AMS Resident & Student Section $8,500

Annual Session $67,000

Educational Programs $24,000

Physicians Health Committee $10,000

MEFFA— Dues $11,600

Legal Guide $1,000

TOTAL $897,690

Governmental Affairs Department

INCOME

Dues $233,575

Income — Misc. Projects $6,000

TOTAL $239,575

EXPENSE

Salaries $1 37,347

Retirement $15,300

Taxes $9,700

Stationery and Printing $4,000

Office Supplies, Telephone, Misc $7,300

Equipment and Furniture $1,500

Auto, Travel and Meeting $50,000

Legal Retainer $18,800

Postage and Communications $1 6,000

Insurance and Bonds $9,100

Office Allocation To AMS $5,000

Audit GA $1,500

TOTAL $275,547

Number 1 1

May 2001 • 375

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Report of the Long-Range
Planning Committee

In 1999, a steering committee was
appointed to guide the Arkansas
Medical Society through a long-range
planning process. The results of that
process were presented at the May 2000
House of Delegates meeting held at the
Embassy Suites in Little Rock. The plan
was approved with the following goals:
provide leadership in developing health
care policy; increase member
involvement in AMS programs and
activities; improve the organizational
strength of the AMS; strengthen the role
of AMS as an advocate for physicians
and patients; position the AMS as the
leader in providing information,
education and assistance to members;
and produce a 15% increase in
membership by 2003.

Three subcommittees have been
established to help the AMS reach these
goals: Membership, Governance, and
Communications. The committee chairs

By Carlton Chambers, MD, Chairman

are Parthasarathy Vasudevan, MD,
Membership; Linda McGhee, MD,
Communication; and Dwight Williams,
MD, Governance. These committees
were challenged to accomplish the
following tasks.

Governance — Review the strengths
and weaknesses of the AMS organizational
structure and, if needed, recommend
changes to ensure broad representation,
meaningful participation, continuity of
leadership and efficient conduct of
business.

Communications — - Investigate and
recommend improved communications
strategies including a review of AMS
publications and use of Internet-based
technology and exploration of the
development of a public relations plan to
promote the AMS and its members’
contributions to health care in Arkansas.

Membership — To develop an
effective physician-to-physician contact

system for recruiting and retaining
members and assist the AMS staff in
identifying effective strategies to
strengthen the bond between physicians
and the AMS.

These committees are still open and
welcoming input from membership.
Please contact the committee chair-
persons with your ideas and desires. The
status of activities and efforts will he
reported at the May 2001 House of
Delegates meeting.

The time and effort extended on
behalf of the membership by the fact-
finding committee cannot be measured.
These groups receive my utmost appre-
ciation and gratitude. I especially thank
the three committee chairpersons and
their members who are working on our
behalf so AMS can continue to respond
to the changing professional and
economic environment faced by phy-
sicians in today’s world. ■

Medical Education Foundation
for Arkansas Report

By Martin Eisele, MD, President

The Medical Education Founda-
tion for Arkansas was organized
by the Arkansas Medical Society
in 1959. Members of the board are Drs.
William Bishop, Little Rock; James Kyser,
Little Rock; Jan Turley, Rogers; and Steve
Shrum, Medical Student Representative.
Serving as ex-officio with voting power
are the AMS president, president-elect,
immediate past president and the dean of
the University of Arkansas College of
Medicine.

The Foundation receives funds con-
tributed by the AMS that amounts to $5
for each full dues-paying member per year.
Since MEFFA is a tax-exempt foundation
(501(c)(3), all contributions are tax
deductible. The Foundation has an
independent audit each year, and a copy

of the audit is provided to the Council.
Funds are used each year to promote the
art and science of medicine and the
bettennent of the health of the public by
providing financial support to recognize
schools or institutions that provide primary
and advanced medical education.

A portion of MEFFA funds is held by
the Arkansas Community Foundation.
Funds from the Arkansas Community
Foundation are expended only upon the
recommendation of the MEFFA hoard.
The board approved the following
expenditures for 2000:

• $8,000 to continue the Distinguished
Lecture Series (10 speakers at $800
each) at UAMS.

• $10,500 to purchase 525 AMS Physician
Legal Guides at $20 each for residents to

use in the new Core Curriculum Series.

• $2,000 to purchase a new computer for
the department of psychiatry.

• $2,700 to purchase a Welch Allyn
Electronic Stethoscope.

• $5,289 to purchase a computer and CD
tower for the department of pediatrics.

• $5,000 contribution to the Ben
Saltzman Chair on Primary Care.
MEFFA has contributed a total of
$25,000 to this chair.

The MEFFA Board also requested
Ken LaMastus draft changes to the bylaws
to include a medical student on the board.
Medical student representatives must he
a member of the American Medical Asso-
ciation and the AMS, a third-year med-
ical student and the president of the Medi-
cal Student Section or their designee.H

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378 • The Journal

Volume 97

Arkansas State Medical Board
2000 Annual Report

The 2000 members and officers of the Arkansas State
Medical Board are as follows:

W. Ray Jouett, MD, Chairman; Warren M. Douglas,
MD, Vice-Chairman; Alonzo D. Williams Sr., MD,
Secretary; John B. Currie Sr., Treasurer; J.R. Baker, MD;
John E. Bell, MD; Sue R. Chambers, MD; Bobbye H.

Dennis; David C. Jacks, MD; Trent R Pierce, MD; Orman
W. Simmons, MD; C.E. Tommey, MD; and James E. Zini,
DO.

The Board met bimonthly and addressed complaints,
hearings, and other pertinent business affecting health care
in the state of Arkansas.

2000 Licensing Statistics

Newly

Licensed

Total

Medical Doctors and Doctors of Osteopathy ..

381

7,852

Medical Doctors and Doctors of Osteopathy (in state) .

5,034

Occupational Therapists

793

Occupational Therapist Assistants

120

Physician Assistants

Respiratory-Care Therapists

109

1,251

Summary of Board Proceedings for 2000

Individual Complaints and Discussions (total) 290

Complaints (including investigations) 1 75

Discussions 1 1 5

Complaints (including investigations)

Advertising 6

Alcohol/Drugs 1 2

Billing Discrepancies 10

Communication or Dr./Patient Conflict 15

Data Bank Report 1

Emergency Room Treatment 3

Ethics 5

Investigation 31

Office Personnel 6

Falsifying Information 3

Failure to Release Medical Records 2

Miscellaneous 1 7

Negligence 15

Practicing/Allowing to Practice without a License 5

Overcharging 1

Overprescribing 10

Overtesting 0

Actions Taken by Other States 4

Lack of Physician Response 1 3

Quality of Care Issue 51

Record-Keeping 0

Self-Prescribing 0

Sexual Harassment 2

Unprofessional Conduct 9

Unauthorized Prescribing 3

2000 Board Actions

Probation 2

Suspension 9

Suspension (stayed) 0

Revocation 5

Revocation (stayed) 3

Surrendered 1

Regulations Passed by the Board
and/or Amended During 2000

Regulation No. 10, Section 3.3

Regulations Governing the Licensing and Practice
of Respiratory-Care Practitioners

3.3 TEMPORARY LICENSE. The secretary of the board
may issue a temporary permit without examination to
practice respiratory care to persons who are not licensed
in other states but otherwise meet the qualifications for
licensure set out in the act. The temporary permit may be
renewable at six (6) month intervals not to exceed a
maximum of two (2) permits per applicant. A temporary

permit will be issued to respiratory-care students based on
the following criteria: a.) Students must be enrolled in an
AMA approved Respiratory-Care program as specified in
Section 7.4, entering their last semester of technical
training, b.) Students must submit a notarized copy of their
current school transcript and a letter of recommendation
that states the expected graduation date from their program
director, c.) Students will practice limited respiratory care
under the supervision of a licensed respiratory-care
practitioner, as specified in Section 7.2 and 7.3.

History: Adopted May 25 , 1988; Amended Sept. 8, 1995,
Dec. 4 , 1 997; Revised March 5 , 1 999; Amended Feb. 3 , 2000

May 2001 • 379

Number 1 1

Regulation No. 24

Rules Governing Physician Assistants

1. A physician assistant must possess a license issued
by the Arkansas State Medical Board prior to
engaging in such occupation.

2. To obtain a license from the Arkansas State Medical
Board, the physician assistant must do the following:

a. Answer all questions to include the providing of all
documentation requested on an application form as
provided by the Arkansas State Medical Board;

b. Pay the required fee for licensure as delineated
elsewhere in this regulation;

c. Provide proof of successful completion of Physician
Assistant National Certifying Examination, as
administered by the National Commission on
Certification of Physician Assistants;

d. Certify and provide such documentation, as the
Arkansas State Medical Board should require that
the applicant is mentally and physically able to
engage safely in the role as a physician assistant;

e. Certify that the applicant is not under any current
discipline, revocation, suspension or probation or
investigation from any other licensing board;

f. Provide letters of recommendation as to good moral
character and quality of practice history;

g. The applicant should be at least 21 years of age;

h. Show proof of graduation with a bachelor’s degree
from an accredited college or university or prior
service as a military corpsman;

i. Provide proof of graduation of a physician assistant
education program recognized by the Committee on
Allied Health Education and Accreditation or the
Commission on Accreditation of Allied Health
Education Programs;

j. Show successful completion of the Jurisprudence
examination as administered by the Arkansas State
Medical Board covering the statutes and Rules and
Regulations of the Medical Board, the Arkansas
Medical Practices Act, the Physician Assistant Act
and the laws and rules governing the writing of pre-
scriptions for legend drugs and scheduled medication;

k. The submission and approval by the Board of a pro-
tocol delineating the scope of practice that the phy-
sician assistant will engage in, the program of eval-
uation and supervision by the supervising physician;

l. The receipt and approval by the Arkansas State
Medical Board of the supervising physician for the
physician assistant on such forms as issued by the
Arkansas State Medical Board;

m. Provide proof of medical liability insurance.

3. If an applicant for a license submits all the required
information, complies with all the requirements in
paragraph 2, except paragraph 2 (k), and the same is
reviewed and approved by the Board, then the applicant

may request a Letter of Intent from the Board, and the
Board may issue the same. Said Letter of Intent from
the Board will state that the applicant has complied
with all licensure requirements of the Board except the
submission of a protocol and supervising physician and
that upon those being submitted and approved by the
Board, it is the intent of the Board to license the
applicant as a physician assistant.

4. The Protocol.

a. This protocol is to be completed and signed by the
physician assistant and his designated supervising
physician. Said protocol will be written in the form
issued by the Arkansas State Medical Board. Said
protocol must be accepted and approved by the
Arkansas State Medical Board prior to licensure of
the physician assistant.

b. Any change in protocol will be submitted to the
Board and approved by the Board prior to any change
in the protocol being enacted by the physician assistant.

c. The protocol form provided by the Board and as
completed by the physician assistant and the super-
vising physician will include the following:

( 1 ) area or type of practice;

(2) location of practice;

(3) geographic range of supervising physician;

(4) the type and frequency of supervision by the
supervising physician;

(5) the process of evaluation by the supervising
physician;

(6) the name of the supervising physician;

(7) the qualifications of the supervising physician in
the area or type of practice that the physician
assistant will be functioning in;

( 8 ) the type of drug-prescribing authorization delegated
to the physician assistant by the supervising
physician;

(9) the name of the backup supervising physicians and
a description of when the backup supervising
physician will be utilized.

5. a. A physician assistant must be authorized by his

supervising physician to prescribe legend drugs and
scheduled medication for patients. Said authori-
zation must be stated in the protocol submitted by
the physician assistant to the Board and approved
by the Board. A supervising physician may only au-
thorize a physician assistant to prescribe schedule
medication that the physician is authorized to prescribe.

A physician assistant may only be authorized to
prescribe schedule III through V medications. The
physician assistant will write prescriptions for
scheduled medications by utilizing a triplicate
prescription form, with the original going to the
patient and the pharmacist, a copy being placed in
the chart of the patient and a second copy being
sent to the Board on a quarterly basis.

380 • The Journal

Volume 97

The requirement of writing triplicate prescrip'
ions and forwarding a copy to the Board may be
waived by the Board after a period of supervised
monitoring by the Board. A physician assistant may
not utilize telephone-prescribing authority when
prescribing scheduled medications III through V.
Prescriptions written hy a physician assistant must
contain the name of the supervising physician on the
prescription.

b. The physician assistant will make an entry in the
patient chart noting the name of the medication,
the strength, the dosage, the quantity prescribed, the
directions and the number of refills, together with t
he signature of the physician assistant and the
printed name of the supervising physician for every
prescription written for a patient by the physician
assistant.

c. The supervising physician shall he identified on all
prescriptions and orders of the patient in the patient
chart if issued by a physician assistant.

6. A supervising physician should be available for imme-
diate telephone contact with the physician assistant
any time the physician assistant is rendering services to
the public. A supervising physician must be able to reach
the location of where the physician assistant is rendering
services to the patients within one hour.

7. a. The supervising physician for a physician assistant

must fill out a form provided by the Board prior to
his becoming a supervising physician. Said super-
vising physician must provide to the Board his name,
business address, licensure, his qualifications in the
field of practice in which the physician assistant will
be practicing, and the name(s) of the physician
assistant(s) he intends to supervise,
h. The supervising physician must submit to the Board
a notarized letter stating that they have read the
regulations governing physician assistant and will
abide hy them and that they understand that they
take full responsibility for the actions of the physician
assistant while that physician assistant is under their
supervision.

c. Backup or alternating supervising physicians must
adhere to the same statutory and regulatory rules as
the primary supervising physician.

8. a. Physician assistants provide medical services to

patients in a pre-approved area of medicine.
Physician assistants will have to provide medical
services to the patients consistent with the standards
that a licensed physician would provide to a patient.
As such, the physician assistant must comply with
the standards of medical care of a licensed physician
as stated in the Medical Practices Act, the Rules
and Regulations of the Board, and the
Orders of the Arkansas State Medical Board. A

violation of said standards can result in the revocation
or suspension of the license when ordered hy the
Board after disciplinary charges are brought,
b. A physician assistant must clearly identify himself
or herself to the patient hy displaying an appropriate
designation; that is, a badge nameplate with the words
“physician assistant” appearing thereon.

c. A physician assistant will not receive directly from a
patient or an insurance provider of a patient any
monies for the services he or she renders the patient.
Payment of any bills or fees for labor performed by
the physician assistant will be paid to the employer of
the physicianassistant and not directly to the
physician assistant.

9. The supervising physician is liable for the acts of a
physician assistant whom he or she is supervising if said
acts of the physician assistant arise out of the powers
granted the physician assistant by the supervising
physician. The supervising physician may have charges
brought against him by the Arkansas State Medical
Board and receive sanctions if the physician assistant
should violate the standards of medical practice as set
forth in the Medical Practices Act, the Rules and
Regulations of the Board, and the standards of the
medical community.

10. Continuing Medical Education:

a. A physician assistant who holds an active license
to practice in the state of Arkansas shall complete
20 credit hours per year continuing medical
education.

b. If a person holding an active license as a physician
assistant in this state fails to meet the foregoing
requirement because of illness, military service,
medical or religious missionary activity, residence
in a foreign country, or other extenuating circum-
stances, the Board upon appropriate written appli-
cation may grant an extension of time to complete
the same on an individual basis.

c. Each year, with the application for renewal of an
active license as a physician assistant in this state,
the Board will include a form which requires the
person holding the license to certify by signature,
under penalty of perjury, and discipline by the
Board, that he or she has met the stipulating
continuing medical education requirements. In
addition, the Board may randomly require physician
assistants submitting such a certification to
demonstrate, prior to renewal of license, satisfaction
of continuing medical education requirements
stated in his or her certification.

d. Continuing medical education records must be kept
by the licensee in an orderly manner. All records
relative to continuing medical education must he
maintained by the licensee for at least three years
from the end of the reporting period. The records

Number 1 1

May 2001 • 381

or copies of the forms must be provided or made
available to the Arkansas State Medical Board,
e. Failure to complete continuing education hours as
required or failure to be able to produce records
reflecting that one has completed the required
minimum medical education hours shall be a
violation and may result in the licensee having his
license suspended and/or revoked.

History: Adopted Feb. 3, 2000

Regulation No. 25

Centralized Credentials Verification Service Advisory

Committe Guidelines

1 . PURPOSE. The Centralized Credentials Verification
Advisory Committee (CCVSAC) is established in
accordance with Act 1410 of 1999 for the purpose of
providing assistance to the Arkansas State Medical
Board in operating a credentialing service to be used
hy credentialing organizations and health care
professionals. The CCVSAC shall advocate the system
throughout the state and work with customers to
identify opportunities to improve the system.

2. MEMBERSHIP. The CCVSAC will consist of ten
(10) standing members who are recommended hy the
CCVSAC and appointed by the Arkansas State
Medical Board, at least six (6) of which shall be
representatives of credentialing organizations which
must comply with Act 1410. Of these six (6) members,
at least two (2) shall be representatives of licensed
Arkansas hospitals and at least two (2) shall be
representatives of insurers or health-maintenance
organizations. The term of each member shall be
annual, and members may serve consecutive terms. Ad
hoc members will be appointed as necessary by the
CCVSAC. Committee members will complete and
file with the secretary a conflict of interest disclosure
statement annually. This statement will be retained in
the permanent records of the CCVSAC.

3. OFFICERS. The Arkansas State Medical Board will
appoint the Chairman of the CCVSAC. The
CCVSAC will elect a vice-chairman and any other
officers or work groups desired. CCVSAC meetings will
be staffed by Arkansas State Medical Board personnel.

4. MEETINGS. Meetings of the CCVSAC will he held
on a quarterly basis, or more frequently if needed.
CCVSAC members will be notified of changes in
operations of the credentials verification service
between meetings. CCVSAC members will be
consulted or informed of major operational changes
before such changes are implemented.

5. POLICIES. It is the intent of the Arkansas State
Medical Board to provide the CCVSAC maximum
input into policies concerning the operation of the

credentialing verification service. Policies will be
developed and adopted concerning:
a. Fees to be charged for use of the service. Fees will be
based on costs of operating the service, and the costs
shall be shared pursuant to Act 1410.
h. Availability of the service. Availability includes time
required to gain access, time allowed in the system,
and geographic availability.

c. Accessibility and security of the service

1. Release of information from physicians.

2. Approval for users to gain access.

3. Password identification requirements.

d. Audit privileges for records maintained hy the
Arkansas State Medical Board. (The CCVSAC will
represent all users and will perform periodic audits in
accordance with established procedure [POLICY FOR
AUDITS, POLICY NO. 95'4] to ensure the integrity
of Arkansas State Medical Board processes and
information available.)

e. Contract format development for subscribers who use
the service.

f. Other policies as needed for operation of the
credentials verification service.

History: Adopted Feb. 3, 2000

Regulation No. 13

WHEREAS, the Arkansas State Medical Board is vested
with discretion (pursuant to Arkansas Code Annotated §17-
95-405 ) to issue a license to practice medicine to a physician
who has been issued a license to practice medicine in another
state, “whose requirements for licensure are equal to those
established by the state of Arkansas” without requiring
further examination; and in order to establish objective
criteria of equivalency in licensure requirements, the Board
hereby finds that all applicants for licensure who were
graduated from an American or Canadian medical school
prior to 1975 and who otherwise meet all other requirements
for licensure in this state shall be determined to meet the
requirements for licensure in this state upon presentation
of satisfactory evidence that they have successfully
completed the examination required hy the licensing
authority in the state in which they were originally licensed.
All applicants for licensure who were graduated from an
American or Canadian Medical School subsequent to 1975
shall he required to present evidence of satisfactory
completion of one of the examinations listed in Regulation
14. Graduates of Canadian medical schools shall he deemed
to have satisfied the equivalency requirements hy providing
proof of completion of the LMCC (Licentiate of the Medical
Council of Canada) examination. Graduates of foreign
medical schools must comply with the requirements of
Regulation 3 and Regulation 14, regardless of the state in
which they are licensed. All applicants must complete and
submit such infonnation as the Board requests on its application
form for licensure by credentials. ■

History: Adopted April 19, 1985; Amended Oct. 6, 2000

382 • The Journal

Volume 97

Report of AMS Benefits Inc.

By Gerald Stolz, MD, Chairman of the Board

A MS Benefits Inc. is a fully owned
subsidiary of the Arkansas Med-
ical Society. Its purpose is to
provide products and services to AMS
members and their clinics. The AMS
president automatically serves as chair of
the AMS Benefits board. Other hoard
members are Drs. Lloyd Langston, Joe
Stallings, Dwight Williams, and AMS
staff members Ken LaMastus, David
Wroten and Lynn Zeno.

AMS Benefits has limited its product
line to insurance products and is licensed
by the Arkansas Insurance Department to
sell life and health insurance products.
This past year has seen a major shift in
how AMS Benefits provides health
insurance products. In July 2000, the
Arkansas Insurance Department assumed
control of Arkansas’ second-largest insurer,
American Investors Life Insurance Co.

At that time, approximately 90
clinics were covered by a group health

insurance plan sponsored by AMS
Benefits and insured by American
Investors.

AMS Benefits staff tried unsuc-
cessfully for more than a year to find
another carrier to underwrite the
sponsored plan. Because of the current
instability in the health insurance
market, it was decided to abandon a
single sponsored plan and instead
individually place each of the 90 clinics
with the health carrier of its choice.

Agent contracts were immediately
sought with each of the major health
insurance carriers, and, within four
months, the task was completed.

In addition to the health insurance
products, AMS Benefits also offers
medical malpractice and a full line of
personal and business insurance
products. This is accomplished through
a relationship with Hoffman Henry
Insurance Corp. The distinguishing

feature of this agency is that it is the only
agency with the ability to write
malpractice coverage for the three major
carriers.

Space does not permit a detailed
explanation of the frustration and
difficulties encountered by our clinic
customers and our staff throughout the
past year in responding to the American
Investors crisis. Credit must he given to
our staff members Alanna Scheffer and
Karen Zimmerman and to Charles
Homer of Hoffman Henry.

Through their tireless work, which
included nearly three months of endless
days and nights, the majority of clinics
have chosen to continue purchasing their
health coverage through AMS Benefits.

Let me take this opportunity to
thank our staff and officers for their
efforts and to encourage our members
to call on AMS Benefits for their
insurance needs. ■

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Number 1 1

May 2001 • 383

Report of the AMS
Medical Student Section

By Dwight J. Johnson, Student Section Chair

The Medical Student Section
has had a very successful and
eventful year. The program at
the University of Arkansas for Medical
Sciences is extremely active in local
and national medical and social issues.
Membership is at an all-time high and
remains at third or fourth on a per
capita basis when compared to other
schools in our six-state region.

We hope many members of the
Arkansas Medical Society have
noticed several new youthful and
enthusiastic faces at such AMS-
sponsored events as “A Day At The
Capitol” or at the annual and interim
AMS meetings. This trend demon-
strates that our grassroots membership
initiative will pay dividends long term
in retained and continuing
membership for our society. Now on to
the specifics.

• Legislative Awareness —
Through the efforts of Lynn Zeno and
students Heather Diemer and Jacob
Dickinson, the students at UAMS are
ready to add their voices and numbers
to any legislative issues identified hy
the Society. For instance, a phone tree
has been created that can he activated
by a single call. This should result in
the presence of 50-100 students at the
state Capitol to canvas and solicit
support for various legislative concerns
that might be raised during the
legislative session.

Students are also kept apprised of
the latest legislative alerts by
dissemination of this information on
the computer file servers at UAMS. All
in all, students at UAMS are now more
aware of legislative issues than ever
before and are willing to support the
Society’s efforts in shaping appropriate
legislative action for the doctors and
their patients in Arkansas.

• Community Projects — The
student section raised more than $960
before Christmas for the under-

privileged children in the special ed-
ucation program at Bale Elementary
School in Little Rock. We used this
money to purchase educational
Christmas gifts for the children and for
educational supplies for several
teachers at the school. Students Lisa
Talbert and Justin McCoy did a great
job soliciting donations and taking care
of the logistical aspects of this project.

The national level of the Arkansas
Medical Association Medical Student
Section recognized our student section
at the 2000 Annual National Meeting
in Chicago with an award for
supporting the national project for the
year. The 1999-2000 national project
was “Organ Donor Awareness.” We
received a $100 award for having the
greatest number of members who are
organ donors.

This year’s national project for the
AMA Medical Student Section is the
Children’s Health Insurance Project
(CHIP). The chair for the Arkansas
version of this program is student
Rebekah Craig-Nunez. She has done a
great job in organizing the students at
UAMS and in premedical programs
across the state to rally behind sign up
efforts to get larger participation in
“ARKids First” (Arkansas’ equivalent
to CHIP).

On Dec. 16, she held the first
medical student-sponsored rally and
sign up program at McCain Mall in
North Little Rock. This effort netted
more than 120 positive sign ups for the
program. This year, she continues to
urge the student section to become
more involved in other activities that
focus on greater participation in the
ARKids First program.

• National Involvement — At the
interim 2000 AMA meeting in
Orlando, Fla., we were honored as a
model chapter for our work on a
project that sought to increase
membership in local, state and national

medical societies. We did this by
approaching senior medical students
and presenting the benefits of
membership in an open forum.

I am currently serving in a liaison
role with the National Board of Medical
Examiners, and student section
members Eric Shultz, Chuck Mashek
and Heather Diemer have been selected
to participate in the AMA’s National
Leadership Conference.

There have been numerous other
students who have served or are
currently serving on national
committees for the student section.

• Local Involvement — On the
local level, students are active in the
changing face of the AMS. Examples
include the many students who are
filling roles on various standing and ad
hoc committees in the AMS, as well
as active committees within the
medical student section, such as the
Legislative Awareness Committee and
the CHIP/ARKids First Committees.

There is never a lack for volunteers
to support any of the initiatives that
are brought to the medical student
body at UAMS. And, beginning in
2002 with the expansion of student
representation in the AMA House of
Delegates, a student from Arkansas
may well sit with the Arkansas
delegation as a voting member.

So as you can see, the students at
UAMS are actively involved in social
and medical issues at both the local and
national levels.

The Medical Student Section at
UAMS would like to extend its great
appreciation to the AMS and all the
doctors in Arkansas for their
continued support and recognition. Be
assured that we seek to work with you
in all of our efforts to improve the
quality of health care for all
Arkansans, and that we stand as a
ready resource to he utilized by the
Society toward that end. ■

384 • The journal

Volume 97

Arkansas Health Care
Access Foundation Inc.

By Michael C. Young, MD, President
and Pat Keller, LSW, CVM, Program Director

“He who
has health
has hope,
and he who
has hope
has

everything. ”
— Arabian
proverb

Again, it is my privilege to serve as
president of the Arkansas Health
Care Access Foundation Inc.
(AHCAF) in the year 2001. 1 consider it
an honor to represent, as well as participate
in providing care through this program.

The progress of this organization has
been extraordinary over the past 12
years! Its dedicated professionals
continue their commitment to provide
for the medical needs of
thousands of Arkansas’
low-income non-insured.
Care such as medical
office visits, prescription
assistance, hospitalization
and dental pain relief is
offered by more than
1,900 volunteer medical
professionals.

More than 3,700
Arkansas enrollees were
covered this year at an
average cost to the program
of only $27 per year.

An estimated $250,000 in care was
donated by the program’s volunteer
medical professionals. More than 2,400
referrals were for treatment, and more
than 600 referrals were for other needed
services. In addition to managing the
program’s services, our two-person staff
handled more than 14,000 telephone
inquiries this year.

Donated Dental Services (DDS), a
service managed hy AHCAF, consists of
volunteer dentists, oral surgeons and dental
laboratories that donate comprehensive
dental treatment to disabled, elderly or
medically compromised Arkansans. This
past year, these dental volunteers provided
$60,000 in treatment. Even with a
treatment waiting list of one to two years,
DDS is a very popular service because it
is the only formal resource of its kind in
the state.

Crucial to the program’s success is the
support of professional associations
representing the medical professionals

involved with the program. We are
grateful to the Arkansas Medical Society
for its ever-present, in-kind support and
assistance. Continued thanks are
extended to the Arkansas Hospital
Association, the Arkansas Pharmacists’
Association, the Home Care Association
of Arkansas, the Arkansas Podiatric
Medical Association and the Arkansas
State Dental Association.

Our profound thanks also to the
Arkansas Department of Human Services
(DHS) for its financial support and the
DHS county offices for their support in
screening the majority of participants.
AHCAF could not function without
their invaluable assistance in linking
individuals with our service.

The foundation continues its
longstanding cooperation with the
Arkansas Department of Health by
providing treatment resources for patients
participating in the Breast and Cervical
Cancer Control Program and those
needing followup for Pap smears.

Thanks goes to Pfizer, Johnson &
Johnson and SmithKline Beecham
pharmaceutical companies for donating
their prescription medicines and again to
Pfizer for covering the cost of reprinting
our applications. Donations to the Tom
Tapp Fund are always welcomed and are
used to purchase necessary medicines
when not donated or affordable for
certain patients.

Continued collaboration with the
Community Health Centers of Arkansas,
UAMS and AHECs, as well as many
faith-based volunteer health clinics, helps
us to reach and assist more Arkansans.

We are especially thankful to our
volunteer board and the AHCAF
volunteer medical professionals for their
untiring commitment and their gifts of
time and energy.

If you are not involved with the
Arkansas Health Care Access Foundation,
please consider volunteering by calling Pat
Keller or Connie Coe at (800) 950-8233.H

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Number 1 1

May 2001 • 385

Physicians’ Health Committee
Arkansas Medical Foundation

By Joe L. Martindale, MD, Medical Director

The Physicians’ Health Committee was fonned to intervene,
assist and advocate for physicians with substance abuse
problems. Funding for the foundation is provided through
an increase in licensure fees of all Arkansas physicians. The
Arkansas Medical Society provides administrative support and
other contributions, such as those from the State Volunteer Mutual
Insurance Co., and a small fee is collected from individuals in the
program. The Arkansas Medical Foundation is a 50 1 (c) (3 ) organiza-
tion. All inquiries and assistance are considered confidential.

Members of the hoard of directors are Larry Lawson, MD,
Paragould, president; Joanna Seibert, MD, Little Rock, vice president;
Karen Ballard, Little Rock, secretary/treasurer; Jerry Stringfellow, MD,
Texarkana; and John Lynch, DO, Jonesboro. Ex-officio members are
Ray Jouett, MD, Little Rock, chairman of the Arkansas State Medical
Board; and Ken LaMastus, Little Rock, executive vice president of
the Arkansas Medical Society.

Activities for 2000 included:

• Participants in our program include physicians, licensed respira-
tory-care therapists, dentists, dental hygienists and optometrists.
• Currently, 73 participants are being monitored, as well as 10
physicians from other states who serve as “locum tenens” in
Arkansas.

• Seven physicians and three dentists have had relapses in the
past four years. Two of these physicians are no longer practicing
medicine, and the other five have successfully completed their
treatment for relapse and are being monitored by the commit-
tee. Two dentists have successfully completed their treatment
for relapse and are currently being monitored by the committee.
One dentist surrendered his license.

• We continue to work with HMOs, PPOs, hospital
credentialing committees, malpractice carriers, probationary
officers, state medical boards, state monitoring programs,
respective Arkansas licensing entities and the DEA to help
physicians to continue practicing medicine and dentistry
in the state of Arkansas.

• We are working with Arkansas hospitals to assist them with
complying with the new JCAH Medical Staff Regulation
MS. 2. 6, which states the medical staff will implement a
process to identify and manage matters of individual physician
health that is separate from the medical staff disciplinary
fashion.

• We continue to keep participants informed of continuing
medical education courses related to substance abuse, pres-
cription writing, sexual issues, ethics, stress management and
other topics of interest.*

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The Journal?
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Gardner at

(501)372-1443

or e-mail

ngardner@abpg.com.

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386 • The journal

Volume 97

Arkansas Department of Health

2000 Report

The Arkansas Department of Health continues its role
in assuring conditions that provide a healthier
quality of life for all Arkansans. In 2000, the
department performed these new activities to improve
Arkansas’ health status:

• Hosted the first Arkansas Cancer Summit to develop a
statewide comprehensive cancer control plan.

• Expanded Hometown Health Improvement. Sites include
Baxter, Boone, Fulton, Madison, Washington, Crittenden,
Scott, Polk, Montgomery, Garland, Phillips, southeast
Pulaski, Drew, Nevada, Pike, and Union counties. Each
community is working to identify its unique health needs.
Several sites implemented programs to address these needs;
others are in the data collection/assessment phase.

• Published “A Look at Diabetes in Arkansas,” defining
Arkansas’ diabetes burden.

• Established a statewide Diabetes Advisory Council to develop
a Diabetes Strategic Plan.

• Partnered with other organizations to establish a “Wellness
Coalition” to address preventive health and chronic disease
needs.

• Partnered with the Centers for Disease Control and
Prevention (CDC) to investigate peripartum cardiomy-

opathy in southern Arkansas and improve evaluation of the
state’s perinatal mortality.

• Conducted the first-ever statewide oral health needs
assessment.

• Reinstated a program to assist Arkansas’ dentists and
physicians in prescribing fluoride supplements for children.

• Initiated the Arkansas Birthing Project to encourage healthier
birth outcomes.

• Began the Promotoras Health Education/Risk Reduction
Program to provide health education in central Arkansas’
Hispanic/Latino communities.

• Received a CDC grant to expand the Early Hearing Detection
and Intervention System.

• Promulgated regulations for Universal Newborn Hearing
Screening in hospitals.

• Received a CDC grant to study falls and fires experienced by
the elderly in Mountain Home, Mena and southeast Pulaski
County.

• Awarded Abstinence Education funds to 14 projects (six
education-based, five community-based and three faith-
based).

• Began developing a centralized core injury information base
for injury data and injury prevention programs statewide.

• Made Pneumococcal conjugate vaccine (Prevnar) available

to private physicians parti-
cipating in the Vaccine for
Children program.

• Implemented Prenatal and
Early Childhood Nurse
Home Visiting in 14 coun-
ties to provide health super-
vision, parenting education
and support to pregnant
teens.

• Completed the Obesity Task
Force study of the impact of
obesity in adults and child-
ren; made prevention and
treatment recommendations.

• Supported initiatives to
address tobacco’s impact on
the state’s minority popula-
tion by coordinating toba-
cco-specific activities tar-
geting minority commun-
ities; funding community-
based planning; partnering
with the University of Ar-
kansas at Pine Bluff to reco-
mmend strategies to prevent

Selected Statistical Indicators

Maternal and Child Health

Screening Pap Smears

... 1,906

Child Health Patients

.. 26,561

EPSDT Screening

...16,840

In-Home Services

Family Planning Patients

.. 56,382

Patient Admissions

. 27,553

Maternity Patients

...14,595

Home Health Visits

303,658

WIC Clients

.145,558

Home Care Visits

104,162

MIP Visits

. 12,515

Communicable Disease Control

Hospice Days

. 37,199

AIDS Testing/Counseling

.. 82,067

Personal Care Hours 1,519,920

TB Skin Tests

.. 90,510

ElderChoice Hours

465,733

Immunizations

Case Management Units

185,627

HIB

103,259

DTAP/DTP/DT

124,567

Substance Abuse Treatment

TD (Adult)

...43,205

Adults Served

..13,105

MMR/MR/Mea

.138,259

Adolescents Served

459

OPV/EIPV

108,952

Regional Alcohol and Drug

Hep B

.225,206

Detoxification (RADD) Patients

... 2,423

Varicella

.. 48,532

Alcohol Safety Education Program

Pneumococcal Conjugate

.... 5,285

Offenders Educated

. 14,203

Breast and Cervical Cancer Control

Laboratory Samples Analyzed

Screening Mammograms

.... 3,182

439,569

Number 1 1

May 2001 • 387

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2001 Programs

May 5 W.W. Stead Chest Symposium

Location: The Austin Hotel, Hot Springs, AR

May 11 The Diamond Conference

Location: The Riverfront Hilton Inn, North Little Rock, AR
May 19 The Diabetes Update 2001

Location: The Holiday Inn Select, Little Rock, AR
June 1-3 23rd Annual Family Practice Intensive Review

Location: UAMS Education II Building, Little Rock, AR

For additional information,

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youth initiation; promote cessation,
eliminate exposure and eliminate
disparities among minority populations
in relation to tobacco use; and
sponsoring the first Minority Tobacco
Summit.

• Partnered with the Arkansas Minority
Health Commission and local churches
to sponsor a Central Arkansas Health
Fair.

• Collaborated with Region VI De-
partment of Health and Human Services
to sponsor a Regional Disparity Health
Conference to develop the best
strategies for eliminating health
disparities.

• Received a grant to assess/plan for
meeting the health needs of Marshall
Island immigrants in northwest
Arkansas.

• Compiled and disseminated a Minority
Health data book for 1993-97.

• Trained six laboratory technicians from
Russia, Hong Kong and Canada in
tuberculosis testing; participated in
training a World Health Organization
laboratory director assigned to Uganda.

• Added the rapid EIA (SUDS) test for
HIV- 1 to support occupational exposure
protocols. Fifteen-minute results allow
post exposure prophylaxis within two
hours.

• Received a CDC Bioterrorism Grant to
increase capacity to test for biological
agents most likely to be used by
bioterrorists.

• Partnered with the UAMS Medical
Technology School to rotate students
through the parasitology and enteric
laboratories.

• Licensed a three million Curie irradiator
to sterilize medical products; licensed a
mobile Positron Emission Tomography
(PET) unit to provide mobile scanning
services.

• Implemented the Radiologic Tech-
nology Licensure Program; licensed
4,089 individuals administering ionizing
radiation to humans.

• Monitored selected water sources for
radon.

• Approved funds through the State
Health Building /Local Grant Trust
Fund to construct or improve health
units in Logan, Pike, Lonoke, Sebastian,
Garland, Polk, Lincoln, Desha, and
Calhoun counties. ■

388 • The Journal

Volume 97

Pulaski County Medical Society
2000 Annual Report

By Carolyn Brummett, Executive Director

Samuel B. Welch, MD, and
board of directors Drs. Anthony
D. Johnson, president-elect;
David E. Bourne, vice president;
Denise R. Greenwood, secretary;
Steven W. Strode, treasurer; and C.
Reid Henry, immediate past president,
led the Pulaski County Medical
Society through a year of unpre-
cedented growth. Membership grew
by approximately 8%, exceeding 1,000
active, emeritus and student members.

To better serve members and see
if the organization was meeting
objectives, the Pulaski County
Medical Society undertook a strategic
planning process. A mail-back survey
of all physicians in the county had a
30% response rate from members and
15% from nonmembers. Both groups
gave “educating the public” and “im-
pacting health policy” the highest
ranking.

Responding to survey results, and
in collaboration with the Arkansas
Medical Society, the Pulaski County
Medical Society launched an
educational campaign in support of a

proposed ban on smoking in
restaurants. The decision to support
this issue publicly was based on
survey results and the planning
process. Arkansas Business published
a guest editorial from the Pulaski
County Medical Society in support
of the ban.

Awareness of the Pulaski County
Medical Society was enhanced
through regular publication of PCM S
News. Issues, members, students and
special events were featured in
Arkansas Business, Arkansas Democrat -
Gazette, AMS Journal and PCMS
News. A Carrier Relations Com-
mittee was formed to improve
communication with insurance
carriers.

Two new social events were
hosted by the Society in 2000 — a
spring social at the home of Dr.
Denise Greenwood and a fall social
at Milford Track Restaurant. The
annual Doctor-Lawyer Dinner was
held at Embassy Suites, and the
Annual Meeting and Christmas
Party was at the Capital Hotel.

The Pulaski County Medical Society
Web site, www.pulaskicms.org, was
activated in 2000. The site offers links
to AMS, AMA and ABMS. The PCMS
Membership Directory is available
through a secure “Members-Only”
section, and a printable membership
application is available as well.

More than 60 members, repre-
senting eight clinics, have taken
advantage of a new Medical Ex-
change service for alpha numeric
paging. The exchange has been
automated with capability for
Internet paging service.

A demographics study of Pulaski
County Medical Society members
indicated that 82% are board-certified,
84% are male and 16% are female.
Practice locations include Little Rock,
81.5%; North Little Rock, 10%;
Jacksonville, 3%; Sherwood, 3%; and
other, 2.5%. Fifty-six percent are
University of Arkansas for Medical
Sciences graduates. Five percent are
graduates of foreign medical schools,
and members represent 19 foreign
countries. ■

CME Accreditation Committee Report

By Steven Strode, MD, Chairman

The Continuing Medical Edu-
cation Accreditation Com-
mittee is charged with the re-
sponsibility to accredit intrastate
sponsors of continuing medical
education (CME). The committee
accredits organizations such as hospitals,
not individual CME activities. Among
other benefits, accreditation bestows
upon an organization the privilege of
designating CME activities for the AMA
Category 1 credit. Only accredited CME
sponsors may designate activities for
AMA credit.

During 2000, the committee met on
three occasions. The committee reviewed
five of our nine sponsors during 2000 and
took the following accreditation actions:

• Conway Regional Medical Center,
Conway — two years full accreditation

• National Park Medical Center, Hot
Springs — two years full accreditation

• St. Joseph Regional Health Center,
Hot Springs — two years full
accreditation

• St. Vincent Infirmary Medical
Center, Little Rock — two years full
accreditation

• VA Medical Center, Fayetteville —
two years full accreditation
Other sponsors are as follows:
Baptist Health Medical Center, Little
Rock; Baxter Regional Medical Center,
Mountain Home; North Arkansas
Regional Medical Center, Harrison; and
Washington Regional Medical Center,
Fayetteville.

CME accreditation is accomplished
under the auspices of the Accreditation
Council for Continuing Medical
Education (ACCME). The national
organization, consisting of seven parent

Number 1 1

May 2001 • 389

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organizations including the American
Medical Association and the American
Hospital Association, has established a
nationwide system of accreditation for
sponsors of CME. The ACCME directly
accredits sponsors whose scope is
national or regional. For intrastate
sponsors, the ACCME has established
a “recognition” system whereby they
recognize certain organizations, usually
state medical societies, to conduct the
accreditation functions within their
state.

In 1999, a recognition survey of the
AMS was conducted by the ACCME’s
Committee for Review and Recognition.
Satisfactory completion of the survey is
a requirement for the AMS to maintain
its “recognized” status.

The Arkansas Medical Society was
approved as an accreditor for intrastate
providers for another four-year term in
March 2000. It is also my pleasure to
have been appointed to the Committee
for Review and Recognition (CRR) for
one three-year term.

The Arkansas Medical Society
hosted the Southeast CME Symposium
with the state medical associations of
Alabama, Mississippi and Louisiana. The
2000 symposium was held in Memphis,
Tenn., and was attended by more than
75 CME coordinators and physicians.

My report would not be complete
without calling your attention to the
amount of time and energy expended by
the committee members and the AMS
staff. For each of the accreditation
decisions mentioned above, many hours
of preparation are involved in reviewing
applications, in conducting the
mandatory on-site survey of the sponsor
and in developing the reports and
summaries of our findings.

In addition, David Wroten and Kay
Waldo handled many inquiries from
sponsors and prospective sponsors, often
necessitating on-site consults at
locations around the state. Many thanks
for the time and effort of our committee
members — Drs. Philip Duncan,
Fayetteville; W. Turner Harris, Little
Rock; Carlton Chambers, Little Rock;
Bob Cogbum, Mountain Home; Joanna
Thomas, Fayetteville; and Anupama
Athota, Little Rock, medical student. ■

390 • The Journal

Volume 97

PEOPLE + EVENTS

HONORED

El Dorado Doctor
Honored with Award

Dr. Bill Scurlock of El

Dorado was recently award-
ed the Ethel K. Millar
Award for Religion and
Social Awareness during the
16th annual SteehHendrix
awards presentation at
Hendrix College in Conway.

Dr. Scurlock is a retired
surgeon who specialized in
general, trauma and vas-
cular surgery. He is a 1956
graduate of Hendrix College
and received his medical
degree from the University
of Arkansas for Medical
Sciences.

As a volunteer, Dr. Scur-
lock takes surgical mission
trips to Third World coun-
tries. He has been inter-
viewed on local and national

news programs concerning
the surgeries he’s done on
these trips.

Besides his mission
trips, Dr. Scurlock is a cer-
tified lay speaker for the
United Methodist Church,
attending physician at the
Migrant Workers Clinic in
Hermitage, and is on the
boards of directors for the
University of Arkansas
Medical Foundation, the
United Methodist Founda-
tion of Arkansas and the
Methodist Children’s Home.
He is also on the board of
governors of the Southern
Arkansas University
Foundation.

Physicians Receive
Awards from AMA

Each month, the Amer-
ican Medical Association
presents the Physicians’

Recognition Award to those
who have completed accep-
table programs of continuing
education.

AMA recipients for Jan-
uary are Drs. H. M. At-
twood of Pine Bluff, Jimmy
D. Bonner of Paragould, Jay
O. Brainard of Little Rock,
James D. Busby of Alma,
Peter J. Carroll of El Dorado,
Jimmy C. Citty and David
M. Evans of Searcy, Richard
L. Hayes of Jacksonville,
Francis P. Maloney of Little
Rock, Robert H. Nunnally
of Camden and Clarence E.
Ransom of Searcy.

OBITUARIES

Charles W. Bailey, MD

Dr. Charles W. Bailey, 80,
of Greenwood, died Feb. 6.

Dr. Bailey practiced
family medicine for 30 years

in Greenwood, was a mem-
ber of the Sebastian County
Medical Society, the Ar-
kansas Medical Society and
the American Medical
Association. He was a
Greenwood School Board
member for 20 years, a
member of Harris-Hannah
VFW Post 6572, a member
of Greenwood First Baptist
Church, a 32nd-degree
Mason, Greenwood Lodge
131 F&AM, and a veteran
of the Army Air Corps and
World War II.

He is survived by his
wife, Waylen; a son, John
Bailey and wife, Natalia, of
Mobile, Ala.; a daughter,
Joan Van Vactor of Au-
gusta, Ga.; a sister, LaRue
Joyner and husband, John,
of Little Rock; and a
grandson, Charles N.
Bailey. ■

New Members

Kimball B. Pate, DO

Specialty: Resident-FP
4010 Mulberry St.

Pine Bluff, AR 71603
(870) 541-6010

Kathleen Paulson, MD

Specialty: OBG
3276 N. North Hills Blvd.
Fayetteville, AR 72703
(5010 442-7030

Jason S. Paxton, MD

Specialty: Resident-FP
601 W. Maple Ave., #102
Springdale, AR 72764
(501) 750-6585

Hilary A. Peterson, MD

Specialty: Resident-EM
11702 Pleasant Ridge Ct, #218
Little Rock, AR 72223

Corwin D. Petty, MD

Specialty: Resident-FP
601 W. Maple Ave., #102
Springdale, AR 72764
(501) 780-6585

Rachel M. Rogers, MD

Specialty: PD

500 S. University Ave., #302
Little Rock, AR 72205
(501)664-4044

Tracy L. Rowe, MD

Specialty: PD
2425 Prince St.
Conway, AR 72032
(501)329-1800

Ron D. Schechter, MD

Specialty: ORS
1000 W. Kingshighway, #10
Paragould, AR 72450
(870) 236-2400

Shailesh R. Shah, MD

Specialty: Resident- AN
4301 W. Markham St.
Little Rock, AR 72205
(501) 686-5000

Walter Short, MD

Specialty: FP
1909 W. Elm St.

El Dorado, AR 71730

David Alfred Sitzes, MD

Specialty: FP
P.O. Box 438
Calico Rock, AR 72519
(870) 297-8081

Lynette Smith, MD

Specialty: PD
101 Skyline Drive
Russellville, AR 72801
(501)968-2345

Todd P. Smith, MD

Specialty: Resident-VS
2200 Fliverfront Drive,
#7308

Little Rock, AR 72202
(870) 257-6859

Edgar A. Sotomayor, MD

Specialty: Resident-PTH
4301 W. Markham St., #502
Little Rock, AR 72205
(501)686-7015

Sarah L. Sullivan, MD

Specialty: FP
State Highway 14 East
Mountain View, AR 72560
(870) 269-4144

Sheila B. Triplett, DO

Specialty: Resident-FP
4010 Mulberry St.

Pine Bluff, AR 71603
(870) 541-6010

Number 1 1

May 2001 • 391

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Richard D. Tutt, MD

Specialty: FP
775 E. Douglas
Prairie Grove, AR 72753
(501) 267-5600

Raymond P. Valdes, MD

Specialty: IM
228 Tyler St., #200
West Memphis, AR 72301
(870) 735-1973

Sara Elsie VanScoy, MD

Specialty: P
2712 E. Johnson
Jonesboro, AR 72401
(501) 268-4115

William R. VanScoy, MD

Specialty: P
2712 E. Johnson
Jonesboro, AR 72401
(501) 268-4115

Imran Waheed, MD

Specialty: Resident-FP
4010 Mulberry St.

Pine Bluff, AR 71603
(870) 541-6010

John Waller, MD

Specialty: ORS
1708 W. Main St.
Heber Springs, AR 72543
(501) 362-6631

Medical Students

Alison A. Acott
Safdar Ali Akbar
John P. Akins
Claudia M. Ancalmo
David E. Arthur
Darrin D. Ashbrooks
Amy E. Bailey
Lisa R. Barker
Jason D. Beck
David L. Bibbs
Samuel E. Bledsoe
Robin I. Bohra
Billynda L. Booth
Leah E. Braswell
Donna Brown
Scott P. Brown
Jenny Campbell
Sherri R. Carter
Sean P. Casey
James E. Cassat
John C. Cawyer
Cari L. Cordell
Krista J. Cordon
Brian W. Counts
Stacy L. Crider
Owen K. Criner
Andrew D. Daniel
Kimberly A. Dannull
Jeremy C. Davis

392 • The Journal

Volume 97

ARKANSAS RETREATS

Tanyard Springs’ guests can enjoy fishing in the Tanyard Pond, which is stocked with bass, catfish
crappie and bream. On the right is the Woodsman cabin, nicknamed “Little House on the Prairie
for its rustic and cozy atmosphere .

Tanyard Springs

Resting peacefully atop beautiful Petit Jean Mountain is a
resort that’s unmatched in Arkansas.

Created by a psychologist, not a developer, Tanyard Springs
offers an atmosphere of rest, relaxation, reflection and
recreation. Visitors can choose to do nothing but unwind in
the comfortable cottages, or they can take advantage of Petit
Jean Mountain’s natural beauty, breathtaking scenery and
panoramic views.

Tanyard Springs is unique in that each of its cabins and
furniture were all handcrafted using natural materials from the
area. And each cabin’s decor is different from one another —
each creatively designed to offer a distinct feeling and
experience. Although each has its own personality, all of them
are authentic replicas of the past.

For instance, the Springhouse cabin was restored from
the original historic building of 1939 where the “purest
spring water in the world” was once bottled. In the
Mountaineer cabin, an entire 35-foot cedar tree trunk forms
the staircase to the quaint loft. The Gambler cabin has a
five-card-stud poker game inlaid in the dining table, and
the Stagecoach cabin features an authentic 1800s stagecoach
transformed into a bed, a favorite with the kids. Another
favorite is the Sheepherder cabin, whose downstairs bed is a
wagon complete with wheels. The other cabins are equally
charming, each taking guests a step back in time.

In addition, all cabins are equipped with a woodburning
fireplace, and pure, natural spring water is piped into each cabin
for both drinking and bathing.

Each cabin comes with porch furniture, an outdoor grill,
picnic table and hammock.

Guests who enjoy fishing should feel right at home at
Tanyard Springs. The Tanyard Pond is stocked with bass, catfish,
crappie and bream. Visitors are welcome to keep the fish they
catch and no license is required. The resort also has miniature
golf, volleyball, horseshoes and a private hiking trail. Tanyard
Springs guests also have access to a private overlook called
Sunrise Point.

And next door to the resort headquarters is Petit Jean State
Park, so visitors can enjoy the park’s swimming pool and tennis
court or just take in the beauty at the park’s six popular overlooks
and hiking trails.

Tanyard Springs is not only known locally but nationally as
well. It was selected by a group of travel experts, along with the
readership of Family Circle magazine, as one of the top five resorts
in North America.

Rates for the cabins vary per night, ranging from $ 1 25, $ 1 50
and $175. Weekly rates are available. A two-night minimum
stay is required on the weekends. ■

Tanyard Springs, 144 Tanyard Springs Road, M orrilton, Ark.
72110. For information, call (501 ) 727-5200.

Number 1 1

May 2001 • 393

ADVERTISERS INDEX

Air Charter Express 392

AMS Benefits Inc 374

Arkansas Business. Com Back cover

Arkansas Financial Group Inc., The 364

Arkansas Foundation for Medical Care Inside front cover

Arkansas Managed Care Organization 376

Asti, William Henry, AIA 385

Central Flying Service 373

Easter Seals 378

EmCare 388

Farmers Insurance Group 386

Fiser Hummer 364

GuestHouse Inn 385

Hoffman-Henry Insurance Corp 370

Lee Pharmacy 378

Little Rock Medical Associates 394

Maggio Law Firm 383

Medical Practice Consultants Inc 372

MedPlus Quotes 373

Micheal Munson, A.G. Edwards & Sons Inc. .. Inside back cover

Mr. Wicks 371

PhyAmerica Physician Services Inc 390

Physicians Management Services Inc 390

Pro Travel 370

Southwest Hospital 371

State Volunteer Mutual Insurance Co 363

Total Document Solutions Inc 392

University of Arkansas for Medical Sciences 372

University of Arkansas for Medical Sciences

Continuing Education 388

Special Publications

Advertising Art Director

Publisher

Nikki Cruse

Brigette Williams

Photographer

Special Publications
Editor- in -Chief

Mark Wilson

Natalie Gardner
Managing Editor

Advertising Coordinator
Kristen Heldenbrand

Shelby Brewer
Editorial Assistant

Marketing Assistant
M itzi Tiffee

Susan Van Dusen

Database Administrator

Sales Manager
Stephanie Hopkins

Andrea Martin
Advertising Assistant

Account Executive
Liz Earlywine

Director of Design

Greg Duszota

and Circulation

^ ARKANSAS BUSINESS

Virgeen Healey

PUBLISHING GROUP

Production and
Circulation Coordinator

Chairman & Chief Executive Officer
Olivia Farrell

Jeremy Henderson

President and Publisher
Jeff Hankins

Editorial Art Director

Executive Vice President

Irene Forbes

Sheila Palmer

Get Published!

Give something back
to your profession...
write an article for

Journal

The /ournal needs your thoughts and
ideas. So why not consider putting your
expertise and experience on paper?

The Arkansas Medical Society is a
statewide organization that represents all
physicians, regardless of location or type
of practice.

The result is a statewide network united
for the common good of the medical
profession. The staff of the Arkansas
Medical Society provides members with
the best information and services
available.

For information about submitting an ar-
ticle to The journal of the Arkansas Medi-
cal Society, call Judy Hicks at 501-224-
8967 or 1-800-542-1058.

SUITES

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LEASING INFORMATION:

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E-mail: egarcia@lrma.com

394 • The Journal

Volume 97

Don’t Stop
Planning Even In
The Face of Estate
Tax Reform

Contributed by:

Micheal D. Munson

Senior Vice President— Investments

A.G. Edwards

1501 N. University, Suite 100
(501)664-9135

Recent stories in the news have discussed
- possible changes of the estate tax laws.
Nothing will probably happen this year, but one
day the estate tax may be reduced or even
eliminated. That doesn’t mean you should throw
your estate plan out the window or delay putting
such a plan in place.

In a flurry of activity before the Republican
National Convention, the Senate voted on and
passed legislation that would have repealed the
estate tax over a ten-year period. Your heirs
would have incurred substantial estate taxes if
you had died before 2010 due to this legislation.
President Clinton has vetoed this particular bill,
but there are 50 bills currently under
consideration in the legislature this year
concerning changes to the estate tax laws.

This bill also includes a provision that would
eliminate the step-up in cost basis at death for
many estates. What does this mean to you?
Presently, only about two percent of estates have
an estate tax liability, but all estates receive a step-
up in tax basis on capital assets to the date of
death value. For example, under current law you
inherit a house purchased by your deceased father
for $100,000. The house is then worth $500,000
at your father’s death. You could sell the house
immediately and pay no capital gains tax because
your cost basis would have “stepped up” to
$500,000. But, if the “step-up” is eliminated on
the house, you could owe $80,000 in taxes if you

sold the house. To come up with that figure you
would subtract the original amount ($100,000)
from the present value of the house ($500,000).
Then multiply that number by 20% capital gains
tax.

The objective of this example is to show that for
every tax reduction, we must expect an increase
somewhere else.

Anticipating tax legislation has always been
difficult if not impossible. Income tax rates were
reduced to 28% in 1987. But in only three short
years, the maximum was raised to 33% and then
to 39.6% three years after that. But the fact that
tax rates and rules can change dramatically and
quickly does not prevent most of us from
planning to reduce taxes.

Likewise, a good solid estate plan will protect
you now and can provide the flexibility to deal
with tax law change in the future. And remember
that estate planning is much broader than simply
reducing or avoiding estate tax. You must also
plan to distribute assets, to manage them for
beneficiaries and to protect yourself and your
family in the event of your incapacity among the
other estate planning objectives. Specific
questions on taxes as they relate to your
individual situation should be directed to your
tax advisor. Your estate plan may make a world
of difference to you and your heirs.

This article was provided by A.G. Edwards &

Sons Inc., Member SIPC.

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Volume 97 Number 12
June 2001

Journal

OF THE ARKANSAS MEDICAL SOCIETY

Winner of the ASAE Excellence in Communications Award

CONTENTS

FEATURES

405 Healing Honduras — Medical Missionaries Tell Their Stories

In some parts of the world, medicine and health care are not as
available as they are in the United States, and unfortunately,
many inhabitants of poverty-stricken villages have never seen a
doctor. Instead, they must depend on the voluntary efforts of
doctors like Dr. Bill Scurlock and Dr. Fred Nagel. Here, both
doctors share with The Journal the stories behind their medical
missions in Honduras and their love of helping the less fortunate.

410 J uggling Careers

If watching “ ER ” episodes doesn’t satisfy your craving for
adrenaline and excitement, just ask Dr. Marvin Leibovich if you
can watch his life for a while. Not only is he the director of an
emergency department, but Dr. Leibovich is also a Little Rock
Police SWAT officer.

420 Common Urologic Problems in Children

Our special article examines common urologic problems in
children. We provide primary physicians with appropriate
guidelines for evaluation and referrals. The problems will be
discussed in two parts. This month’s Part I will cover urinary
tract infections, voiding dysfunctions, hematuria and proteinuria.

DEPARTMENTS

It’s not uncommon for 15 people to
live under one roof in Honduras .
Physicians Bill Scurlock, Fred Nagel
and Charles Lane Jr. share their
stories.

— page 405

401 Commentary

William Ackerman, MD

403 What We’ve Done
For You Lately

412 Loss Prevention
414 Radiology Report
416 Case of the Month
418 A Closer Look at Quality
422 People + Events

426 Arkansas Retreats

427 Index to Advertisers

428 Volume Index

Jo. i llpT

Dr. Marvin Leibovich shares how he
wears several hats — that of an
emergency room physician and a
Little Rock Police officer.

— page 410

On the Cover: Dr. Fred Nagel (left) , a
family doctor from North Little Rock, carries
a sick patient to the clinic site in Trujillo,
Honduras. On the right is Dr. Bill
Scurlock, a retired surgeon from El Dorado.
Like Dr. Nagel, he also did medical missions
work in Honduras .

Photos courtesy of Arkansas Democrat-Gazette and Lisa Nagel

Number 1 2

June 2001

399

THE ROAD TO ANTIBIOTIC RESISTANCE

Act 12

ENTER STAGE LEFT

Antibiotic (solo):

See me, world, for who I am ... I'm a
dedicated fighter against bacteria.

BUT I'M NOT INVINCIBLE!

Oh how I wish I could, but I simply
can't cure every illness.

I HAVE LIMITS!

I'm powerless against viruses -
colds and coughs. I don't work.

The virus is a villain that must
be allowed to run its course.

OH WORLD, SEE ME FOR WHO I AM!!!!

EXIT STAGE RIGHT

Arkansas Foundation
for Medical Care

Save the Antibiotic.

Don't use it when you don't need it

ARKANSAS
DEPARTMENT OF

HUMAN

SERVICES

www. savetheantibiotic .com

COMMENTARY

COMMUNICATIONS COORDINATOR

Judy Hicks

EXECUTIVE VICE PRESIDENT

Kenneth LaMastus, CAE

ASSISTANT EXECUTIVE VICE PRESIDENT

David Wroten

EDITORIAL BOARD

Sue Chambers, MD
Joseph M. Beck, II, MD
Lee Abel, MD
Samuel Landrum, MD
Jerry Kendall, MD
William Ackerman, MD

Pediatrics
Oncology
Internal Medicine
Surgery
Family Practice
Anesthesiology

EDITOR EMERITUS

Alfred Kahn Jr., MD

ARKANSAS MEDICAL SOCIETY
2000-2001 OFFICERS

Gerald A. Stolz, Jr., MD, Russellville
President

Joe Stallings, MD, Jonesboro
President-elect

Paul A. Wallick, MD, Monticello
Vice President

Lloyd G. Langston, MD, Pine Bluff
Immediate Past President

CarltonL. Chambers, III, MD, Harrison/Little Rock
Secretary

Dwight M. Williams, MD, Paragould
Treasurer

Anna Redman, MD, Pine Bluff
Speaker, House of Delegates

Kevin Beavers, MD, Russellville
Vice Speaker, House of Delegates

Joseph M. Beck, II, MD, Little Rock
Chairman of the Council

Established 1890. Owned and edited by the Ar-
kansas Medical Society and published under the di-
rection of the Council.

Advertising Information: Contact Stephanie
Hopkins, P.O. Box 3686, Little Rock, AR 72203;
(501)372-2816.

Postmaster: Send address changes to: The Journal of
the Arkansas Medical Society, P. O. Box 55088, Little
Rock, Arkansas 72215-5088.

Subscription rate: $30.00 annually for domestic;
$40.00, foreign. Single issue $3.00.

The Journal of the Arkansas Medical Society
( ISSN 0004- 1 858) is published monthly by the Arkan-
sas Medical Society, #10 Corporate Hill Drive, Suite
300, Little Rock, Arkansas 72205. Printed by The
Ovid Bell Press, Inc., Fulton, Missouri 65251.
Periodicals postage is paid at Little Rock, Arkansas,
and at additional mailing offices.

Articles and advertisements published in The Jour-
nal are for the interest of its readers and do not
represent the official position or endorsement of The
Journal or the Arkansas Medical Society. The Journal
reserves the right to make the final decision on all
content and advertisements.

Can Business and Science
Coexist in This Century?

By William Ackerman, MD

Penicillin is an effective antibiotic that has a wide margin of safety. Many derivatives
of penicillin have been synthesized since its discovery by manipulation of its basic
stmcture. The story of penicillin’s discovery is a model for biomedical progress.

In 1929, Flemming was working with staphylococcus variants. On his laboratory bench
he set aside a number of culture plates. The plates were exposed to air and were contaminated
with various microorganisms. Flemming noticed that a contaminating mold would cause
lysis of some of the staphylococcus colonies. Flemming published the results of his findings
in the British Journal of Experimental Pathobgy in 1929.

After the discovery of the antibiotic properties by Flemming, the compound was
dormant for a decade until further biochemical studies were done by Florey and the age of
chemotherapy was discovered.

This story exemplifies Pasteur’s saying: “That in research chance prepares only the
prepared mind.” Louis Pasteur discovered a method to stop milk from spoiling. Both the
scientific and lay communities thought that these discoveries were admirable. Today things
have changed. There is an increasing feeling that science and business should not mix.
There appears to be a feeling in Washington that the art of scientific discovery is tainted
if driven by profit.

Rep. Marion Berry from Arkansas is a pharmaceutical company critic. Rep. Berry
alleges that some drug companies overcharge patients who need a certain medication. “I
think what they’re doing is immoral and it should be illegal,” Berry said.

Mylan labs recently settled a lawsuit for $100 million for alleged price gouging. On
the other hand, many pharmaceutical companies furnish free medications to those
individuals who require a specific drug but are unable to afford it.

President George W. Bush promised to provide dmg coverage to the elderly and disabled
under Medicare. The congressional budget office underestimated by one-third the amount
needed to pay for proposed Medicare dmg benefits. As a result, it will be more diff icult for
Congress to pay for dmg benefits.

Many phannaceutical companies are publicly owned and are in business to make a
profit for their shareholders. Developing dmgs is expensive. Research and development
costs average about $500 million for each new dmg developed in the United States. If
dmg companies are to continue to develop new dmgs they must make enough profit to
meet the costs of the dmgs that are effective, but also meet the costs of the dmgs that are
not effective.

The underlying debate between some legislators and dmg companies is the terms on
which scientific knowledge can be owned. Any pharmaceutical company that owns a
patent on a particular dmg is held to rigorous standards in order to obtain that patent.
Should the financial incentive for developing new medicines be eliminated or decreased?
Is it better to have a new expensive dmg or no dmg at all? Should the federal government
subsidize pharmacologic research? There are no easy answers to any of these questions.

The Pharmaceutical Research and Manufacturers of America favor a federal subsidy
program that would help needy individuals pay for insurance that would cover the cost of an
individual’s dmgs. Rep. Berry is skeptical that this plan would work. He said representatives
from insurance companies have said that such a plan is not workable. Insurance only works
when a small number of policy holders collect on their policies, they said.

It is obvious that both the lawmakers and the phannaceutical companies must make
some compromises as to what is ethical and what is unethical when science and business are
partners. We as physicians should be aware of the costs of medications that we prescribe.
We should prescribe medications with attention to both cost and efficacy. We should
furthermore document those instances where a patient is unable to obtain a medication
that the physician deems is medically necessary. These cases should be reported to the
Arkansas Medical Society, who in turn should report this infonnation to the American
Medical Association. These statistics could be useful for the establishment of a dmg subsidy
program that might actually work. ■

Number 1 2

June 2001 • 401

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402 • The Journal

Volume 97

WHAT WE’VE DONE FOR YOU LATELY

a New Service Allows

Physicians to "Connect"
With Their Patients

By David Wroten

The use of Internet technology continues to grow, especially as a means of
communication and a source of infonnation. For instance, do a search for asthma
on any search engine and you’ll find thousands of Web sites. Unfortunately,
though, no one is out there ensuring that the infonnation on these sites is clinically
valid. This gives new meaning to the old adage, “let the buyer beware.”

Make no mistake, your patients are using these Web sites to learn more about
their medical conditions, treatment, and even to selhdiagnose. The Arkansas Medical
Society believes that physicians can play a significant role in pointing their patients
toward medical information that they can trust. And now, the AMS has the tool to
help physicians fulfill that role and use the Internet to communicate “securely” with
their patients. It’s called “Medem.”

Medem is a secure online physician network founded by seven national medical
specialty societies and the American Medical Association. It offers secure messaging,
access to reliable health information and customized physician Web sites. In April,
the Arkansas Medical Society became the 27th medical society to join the Medem
partnership.

What is a “secure online physician network” ? Through Medem, AMS members
can communicate confidential infonnation to their patients over a secure Web site,
ensuring that the infonnation will remain confidential. Patients will be able to request
prescription refills and test results, schedule appointments and get medical care
information 24 hours a day, seven days a week. Not only can this he a valuable service
to patients, hut it also has the potential to create efficiencies for the office staff.

How about the asthma search mentioned earlier? The Medem network will provide
patients with the most credible, trustworthy and high quality health information on
the Internet. How can I say that? Simple, the information will come from, or he
approved by, the nationally recognized medical societies that make up Medem. For
example, I believe I could place a high degree of trust in clinical information from the
American Academy of Pediatrics — a Medem founder. Or how about the American
College of Allergy, Asthma & Immunology? Another Medem founding organization.

What’s more, patients will access this infonnation and the secure messaging
through their physician’s own Web site built hy Medem. Patients will go to “their
doctor” for health information, a feature that is designed to build a stronger patient-
physician relationship and help solidify the physician’s role in providing accurate,
reliable medical information.

So, what have we done for you lately? Through this partnership with Medem,
AMS members have an opportunity to build their own Web site for communicating
effectively and confidentially with their patients, which can also be accessed by those
patients for the most current and credible medical information available on the
Internet.

This is indeed an exciting opportunity for Arkansas physicians. Even better, it’s
being offered free to members of the Arkansas Medical Society. Now that’s a member
benefit!

To learn more about Medem, visit the AMS Web site at www.arkmed.org, or go
directly to the Medem Web site at www.medem.com. ■

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a higher calling

Arkansas Doctors
Lend a Helping Hand
to Hondurans

Photo courtesy of Arkansas Democrat-Gazette

By Shelby Brewer

IF YOU'RE LOOKING FOR A SURE WAY TO MAKE
PEOPLE SMILE, JUST MENTION THE WORD
VACATION. PEOPLE CANT HELP BUT SMILE AS
IMAGES OF SANDY, WHITE BEACHES
ANDTROPICAL DRINKS WITH TINY UMBRELLAS
DANCETHROUGH THEIR MIND.

Now mention a vacation with extremely hot
weather, no air conditioning, no electricity, long
hours, crowded and unsanitary conditions and
miles of sick people. More than likely, you won’t get the
same happy expression.

But the doctors who spend their vacations laboring under these
conditions smile. And they’ll tell you it’s the best vacation they’ve ever
had.

These doctors are known as medical missionaries. They don’t
take classes on how to be a missionary, and their skill levels aren’t
necessarily higher than other doctors. Instead, these medical
missionaries are just your regular, everyday doctors who’ve decided
to use their medical abilities to help the less fortunate.

The reasons why these doctors are hooked on spending their
vacations, as well as their own money, in poverty-stricken countries
vary.

For instance, Dr. Charles Lane Jr.’s reason is one that's close to
his heart. A retired otolaryngologist in Fort Smith, Dr. Lane was about

to retire in 1986 when suddenly
he felt there was something else
left to do. His feeling took him all
the way to India and St. Vincent
Island in the southern part of the
Caribbean, where he completed
many surgeries. After those two
trips, the 81-year-old decided it
was time to end his mission work

Top photo: The plane carrying
medical equipment for Dr. Bill
Scurlock and his surgical team comes
in for a landing on a mountain in
Honduras. Far right Patients wait in
the crowded and unsanitary hospital
in Trujillo, Honduras. Bottom left Dr.
Scurlock talks to patients awaiting
surgery in Gualcinse, Honduras,
where he has done medical mission
work for 20 years.

and retire for good.

But his wife’s death in December 1993 changed all that. "I think
God laid it into my heart to get back into mission work," he said.

Only a few months later in 1994, Dr. Lane received some mail
about the World Medical Mission, an organization which sends doctors
across the world to witness to Christ and do medical mission work.

Number 1 2

june 2001 • 405

Photo courtesy of Arkansas Democrat-Gazette

FACES OF POVERTY — Shown here is a typical one-room house in Trujillo, /Honduras , where a mother and her 1 3 children live. Dr. Fred Nagel and his wife, Lisa
Nagel, return to this village each year to perform medical mission work.

After applying, he received a call two
weeks later requesting an otolaryngologist in
Papua New Guinea.

“After that, I was totally convinced that
God wanted me to get back into mission
work,” he said. Dr. Lane eventually made five
trips to Papua New Guinea and said it was
one of the greatest experiences of his life.

“It's been one of the ways God has shown
me a reason for my wife's death,” he said.
"I’ve been one of the fortunate individuals to
see a real reason why the Lord took her.”

Like Dr. Lane, other doctors have also felt
a calling to become medical missionaries.
Here are the stories of two such doctors who
have humbly made a difference in the lives of
thousands.

Mission Gualcinse

It was after sunset nearly 20 years ago
when Dr. Bill Scurlock rode a mule into the
small, remote village of Gualcinse in western
Honduras. There was no electricity and the
town was dark. Accompanied by his surgical
team — two anesthetists, two scrub nurses,
an automobile mechanic and a Louisiana state
trooper — Dr. Scurlock had traveled from El
Dorado, Ark., for a very important reason —
to operate on thousands of sick Hondurans,
most of whom had never seen a doctor in their
lives.

For almost two decades, the 67-year-old

retired surgeon has been doing volunteer
mission work, and was recently honored for
it with the Ethel K. Millar Award for Religion
and Social Awareness given by Hendrix
College in Conway, his alma mater.

Dr. Scurlock’s been to such countries as
Siberia, Russia, Africa, Haiti and Mexico, but
his real story, he said, is Honduras.

Dr. Scurlock learned of Gualcinse’s need
for a surgeon from an American missionary
who was already living there. The missionary
had issued an urgent plea to the United States
for surgeons, so Dr. Scurlock gathered up a
team of volunteers from the El Dorado area
and boarded a plane.

Once the team arrived in Gualcinse, they
unloaded their equipment into a stucco-mud
building with dirt floors. This served as the
clinic where the team would perform
surgeries. Dr. Scurlock said he didn’t sleep
much that first night, particularly because
there was a war going on with Nicaragua at
the time and it was in their area.

At dawn, he opened the board window
and was shocked at what he saw. “There was
a solid line of humanity that extended all the
way down the street with every conceivable
surgical problem you can imagine," he said.
These were the patients the missionary had
scheduled for surgery.

The team quickly improvised two
operating rooms. In one room, they used the

fog light of an automobile hooked to a car
battery and powered by a small, gasoline
generator for light. In the other room, they
used a table from the local Catholic church
and a flashlight. The instruments were
sterilized in a pressure cooker over an open
fire, and the anesthesia machine, which had
been dismantled and brought in pieces, was
reassembled by the light of a kerosene
lantern. The mechanic and state trooper
served as the surgical assistants. Neither
had been in an operating room before.

Dr. Scurlock said the team did 70
operations that week, ranging from
hysterectomies, hernia repairs, mastectomies,
removal of ovarian tumors and operations for
congenital defects. Patients were brought in
on stretchers as far as eight miles away, he
said.

When they left 10 days later, Dr. Scurlock
said the line of people waiting for surgeries
was still just as long.

A Need So Great

What made that first trip so special to Dr.
Scurlock is that he learned a valuable lesson
from one of the Hondurans — one that he will
never forget. He has since shared this story
with many people, including Peter Jennings
on ABC’s “World News Tonight” in hopes that
it will raise awareness of the need for doctors
in Third World countries.

406 • The Journal

Volume 97

Photo by Lisa Nagel

Photo courtesy of Arkansas Democrat-Gazette

"I examined a man with far
advanced cancer on his abdomen that
was inoperable. So with my limited
Spanish, I told him. ‘Sir, you came too
late.'

"And he looked up at me and
replied, ‘No sir, I’ve been here all my
life. You came too late.”'

After hearing those words, Dr.
Scurlock promised himself that he would
come back to the village every year, and
he has done so for the past 20 years.

Dr. Scurlock said he’s proud of what
he and other volunteers from the El
Dorado area have accomplished in two
decades. I’ve done more than 500
operations there without a single
complication, he said, and that’s with no
blood, X-rays or laboratory facilities. In
addition, the volunteers have built a dam
and waterline to provide clean water,
constructed a concrete building to do surgeries
and built five churches.

On his final trip to Honduras last year, Dr.
Scurlock said as he was riding the bus into the
village, he saw what he thought was a mirage.

"There was a big, 12-room hospital with
a modern pharmacy, operating room,
laboratory and a $50,000 generator given by
the country of Spain,” he said. “So in 20 years,
we’ve gone from a mud hut to a fairly modern
hospital.”

Dr. Scurlock said he became interested
in mission work when he was in the army.

“I was in the Vietnam War and was drafted
out of practice, and I saw that these Third World
countries have no access to surgery. "

Dr. Scurlock laughs when he describes
his first medical missions trip, or rather,
attempted trip. When he got out of the army,

Top photo: Dr. Bill
Scurlock and his
wife treat a
patient in
Gualcinse,
Honduras.

Bottom: Dr Fred
Nagel talks to a
young patient
before examining
her. He said one
of the rewards of
doing mission
work is
developing
relationships with
the patients.

Photo by Lisa Nagel

he and other doctors drove to Mexico in the
late 1970s and turned a school bus into an
operating room, but country officials quickly
ran them out. “They thought we were drug
dealers,” he said.

When asked why he enjoys medical
missions work, his answer is quite simple —
because it’s refreshing, he said.

“When we were in medical school, we all
had one desire — and that's to cure the world
and do good,” he explained. “But then when
you get into practice, over a period of time,
things change and other factors move in.
Then you’ve got the business side of it, the
legal side, the government intervention and
the paperwork. In mission work, you do what
you wanted in the first place — a one-on-one
doctor/patient relationship where the patient
has full confidence in you.”

Dr. Scurlock said it cost him about $800
for each trip and he had to use his vacation
time, but that didn’t bother him.

“There's no better or more relaxing way
to take a vacation than to do that work. I know
that sounds funny, but it’s true. Go to Florida
and you’ll forget the trip, but go to Honduras
and you’ll remember it for the rest of your life.”

Mission Trujillo

For Dr. Fred Nagel, a 45-year-old family
doctor at North Little Rock Family Practice,
the real vacation starts once the mission trip
is over.

“I think mission trips put things in
perspective,” he said. “As busy as you think
you are here, when you go on a missions
trip, you work much harder and it drains
you physically and emotionally. So when
you come back it’s like a vacation — your
patients are all nicely scheduled ... you
have air conditioning."

But despite the hard work, Dr. Nagel
wouldn't think twice about going on
another missions trip. In fact, he just
returned from a missions trip in March
and is already planning one for next year.

Dr. Nagel became involved in
missions work five years ago when he
and his wife went on a missions trip to
Trujillo, Honduras, with other members
of their church, Christ the King Catholic
Church. Since then, he’s gone on every
mission with the church group and he and
his wife, Lisa Nagel, a nurse practitioner,
are now the directors of the mission.

Their mission is divided into several
parts, he said, including evangelization,
construction and medical. The medical
part of the mission includes a hospital
and three clinics — medical, eye and

dental — situated in outlying villages.

The volunteers are divided and assigned
to a site based on their skills or professions.
For example, three surgeons work at the
hospital site while three primary care
physicians work at the medical clinic.

“We see about 1 ,000 patients during the
week at each site,” Dr. Nagel said. “Since the
first mission five years ago, they’ve seen 6,000
patients.”

The group takes prepackaged medicine
in a dose form with them so they don't have
to waste time sorting out pills there, he said.

About 90 people with a variety of
professions from the church participate each
year, he said. Their mission lasts seven days
with two days for travel, and the travel can be
pretty strenuous, he said. For example, once
the group gets off the airplane at San Pedro
Sula, they must then ride a bus for six hours

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on a bumpy, dirt road to Trujillo — and it’s a
very dusty journey he said. In fact, the dust is
so bad that they must wear masks to avoid
inhaling it, mainly because the eggs of
parasites live in the dust, which is why a
majority of the Hondurans have worms.

Treating patients with worms was often
routine for Dr. Nagel.

“I was in the back of the building seeing
a patient when all of a sudden I heard a lot of
commotion in the waiting room, so I went to
see what it was about. Standing there was a
little girl, about 7 years old, who had just
coughed up a worm. It was squirming around
on the floor next to her and it was big, like the
size of a fishing worm. Everyone had cleared
away from her. So we captured it and brought
it back in a jar of alcohol to show the people at
church that the stories you hear about people
getting worms are true."

Besides hook worms and round worms,
other conditions that were prominent among
the villagers included malaria, diarrhea,
malnutrition, skin infections, fungal infections,
denque fever and chagas fever.

The challenge, he said, was trying to treat
these patients with little or no diagnostic
testing. “And on top of that, it’s complicated
by our unfamiliarity of these tropical diseases
— sometimes we've only read about them in
our medical text as students.”

In addition, Dr. Nagel said many of the
children are born with congenital defects,
cerebral palsy and other deformities — some
of which the doctors can do nothing about.
However, the surgeons have done miraculous
work on the children by repairing such
deformities as cleft lips and palette,
orthopedic injuries and club feet, he said.

A Different World

Dr. Nagel said most of the families are
extremely large, having six to 14 children. He
remembers seeing a young mother walking
barefoot while carrying both a baby and an
older child with a deformity.

A lot of families from surrounding villages
would walk three to four hours to the clinics
because it’s their only shot at medical care.

The typical family housing was a thatch-
roofed hut with clay walls, usually having just
one room with no electricity or water. Dr.
Nagel said the village’s hospital, where the
volunteer surgeons worked, was very
unsanitary and in total disrepair, and on their
first trip they discovered all the toilets were
backed up and the smell was unbearable.
So the first thing the volunteers did was put
in a sewage system. They also brought a
big generator to supply the hospital with
electricity, and they refurbished two

operating rooms. Each year, the group also
donates equipment to the hospital, such as
a sterilizer, anesthesia machine and EKG
monitor.

Each day of the mission, the volunteers
would have mass at 6 a.m. followed by
breakfast. They’d open the clinics at 8 a.m. and
work until 5 p.m. Dr. Nagel said the challenge
was to get the most critically ill seen first.

“You can’t see everybody, and it feels
like you’re just able to do very little," he said.
“It’s just a minor drop in the ocean compared
to the overall scheme.”

Another obstacle, he said, is that the
volunteers are only able to offer short-term
solutions to long-term problems.

“We can give them vitamins and
treatment for parasites, but the vitamins will
run out and the parasites will come back, so
we try to offer them something more long term
in the form of patient education. We teach
them things like personal hygiene, water
purification and sanitation, safe food
preparation, and we give them things like
soap, toothbrushes and baking soda.”

Overall, Dr. Nagel said the missions
have made him a better person. “It makes
you appreciate all you've been blessed with.
It puts things into perspective so that you
don’t get as wrapped up in materialism as
so much of us tend to do."

He said meeting the Hondurans has also
been an eye-opener to him.

“It makes you realize that Americans,
interestingly enough, are the ones you
should pity, when you think it would be just
the opposite, because Americans are lost
in the way they live. They live too fast to
enjoy life; they’re too wrapped up in money,
materialism and other worries,” he said.
“You’d think that these people who have
nothing and are starving would be
depressed, but they’re the happiest people
I’ve ever seen. They always have a smile
on their face, and they’re so appreciative
of what you do for them.”

Dr. Nagel said there are several rewards
from doing mission work. “Probably the best
is treating a patient that you've seen before
to see how you've helped them,” he said.
And since the church group returns to Trujillo
each year, Dr. Nagel said he’s developed
relationships with the locals and considers
them his friends.

“It's certainly not for everybody,” he said.
“I think there is a calling for it, just like there is
a calling to be in medicine, but I also think it’s
an obligation. We’re given so many gifts and
blessings that we should share with other
people we have a duty to help those who are
less fortunate." ■

408 • The journal

Volume 97

k ri r m rot e J\f . nd if .a? I. 5a a at y
Tnaurfmca Pmfcrme,

AMS BENEFITS, INC.

A wholly owned subsidiary of the
Arkansas Medical Society
P.O. Box 55088

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By Shelby Brewer

Meet Our Members

Marvin Leibovich, MD

Dr. Leibovich, a Little Rock
Police SWAT officer,
prepares for a possible drug
bust with his team.

Photo: Mark Wilson

“I’m very glad I chose medicine. It’s a great career and I’m
always thrilled with the excitement of the emergency
department.”

You would think that the heart-pounding excitement of
an emergency room would be enough for Dr. Leibovich, but
apparently not. When one of his patients offered him another
adrenaline'filled job, he jumped at the chance.

“One of the officers on the team, Danny Sabo, came into
the emergency department as a patient. We got to talking and
he said, ‘You know, we could really use a doctor on the team.’ It
sounded interesting and fun, so I went to training a week later,
and I’ve been with them ever since.”

As a member of the SWAT team, Dr. Leihovich’s primary
mission is to provide medical support for the team members
and he ready to treat any injuries should they occur. He said it
only makes sense for a doctor to be on the SWAT team.

“We send physicians to basketball and football games, but
there’s certainly no more dangerous situation than a tactical
police operation where you’ve got a barricaded suspect professing
he’s going to kill anyone who tries to take him alive.”

So how does he juggle both careers? “Very easily,” he said.
“I think a good emergency physician should he able to practice
his skills just as comfortably in the field as he does in the
emergency department.”

And he does just that. As medical director of the emergency
trauma department, Dr. Leibovich works closely with the
administration to develop policies and procedures, hut he also
works as a full-time emergency physician. He rides with the
SWAT team one night a week, trains with them two days a
month and goes on all the SWAT call-outs.

Fortunately, he said, he’s been able to balance the two
careers because of the support he’s received from his co-workers.

“I’ve got some great partners, and they’ve been able to cover
me so that I can get away in a quick period of time
if I’m called out,” he said.

He drives a SWAT car to work, which has
his gear, guns and uniform already in it so that
whenever he’s paged, all he has to do is walk
out the door.

The 54-year-old doctor has been on
the SWAT team since 1992, and since
then he’s been involved in several drug
raids and riots and has taken care of
people who have been shot or injured.
But he’s most proud of what he has
done for each individual team
member.

Volume 97

It’s 3 a.m. and the phone rings. It’s the emergency room. There’s
been a bad wreck on the interstate, and three people are severely
injured. While throwing on your white coat, you jump into the car
arid race to the hospital. But on the way there your pager goes off.
It’s your SWAT commander. A riot Irroke out at a bar, and they
need you at the scene in case someone gets hurt.

For most doctors, this lifestyle probably seems like a
nightmare, but for Dr. Marvin Leibovich, it’s a dream come
true — and he’s living that dream today.

You see, not only is Dr. Leibovich the medical director of
the Emergency Trauma Department at Baptist Health Medical
Center, but he’s also a member of the Little Rock Police SWAT
Team.

He never planned on having two careers, though, especially
not a career in medicine. “When I was in college, I was going to
be an attorney. And unfortunately, I was bom beautiful instead
of wealthy,” Dr. Leibovich said, laughing, “so I had to work.

“I got a job working in the ER at a hospital in Memphis
hack in 1966, and I always caught myself looking in the hack
because that’s where all the action was. So I asked the head
nurse il I could be an orderly so I could work back there, and I
fell in love with it.”

He changed his major to premed, specialized in emergency
medicine and never looked back.

“I’ve worked up a medical form for
each member of the team, and we keep it
in our SWAT van so that if one of the
officers is ever injured, I’ve got all his
medical background information, routine
medication and drug allergies with me. I
also participate in their physical fitness
training program and give them input
with that. Basically, I try to ensure the
health of each member. I’ve kind of
become a family doctor to them.”

When comparing his two jobs, Dr.
Leibovich said they have a lot in
common. “In emergency medicine,
there’s no typical day. There’s an awful
lot of stop and go. It goes back and forth
between minor illnesses that really don’t
need to be treated in an emergency
department to major trauma, and that’s
the parallel to police work. Sometimes
it can he boring, boring, boring, hut then
all of a sudden someone comes in with a
knife stuck in his chest.”

Another common aspect of the two
careers is that you have to be an
adrenaline junkie to be successful, he
said.

“And that’s my personality. I’m an
adrenaline junkie. My police work takes

that adrenaline another step higher,” he
said. “There’s a certain magic to being the
only person there at 3 a.m. when someone
wanders through the door who’s been shot
in the chest, and you have to make
instantaneous, life-saving decisions.”

Dr. Leibovich said that although there
are a lot of heartaches involved with
emergency medicine, the rewards make it
all worth it. “The real reward is knowing
that there are people alive who otherwise
might have perished had you not been
there to provide immediate interventions,”
he said.

One of the challenges of his work,
however, is dealing with patients who
sometimes abuse the emergency de-
partment. “Unfortunately, there are some
patients we get to know very well. We call
them the repeat offenders,” he said. “They
come in 10-15 times a year. The other day
we had a lady call the ambulance because
her foot hurt.”

He said emergency departments across
the United States are in critical condition
right now. “They’re overcrowded, there’s
not enough staffing and we get in a
gridlock situation here. At any one time,
several hospitals in Little Rock may be on

diversion for all ambulance traffic because
their hospital is out of critical care beds,
the emergency department is completely
full and doctors are treating people in the
hallways.

“The challenges are both to he able
to provide excellent patient satisfaction
at a time when there is increased demand
and workload for the staff,” he continued,
“and ensuring that every patient has
received quality emergency care.”

In addition to serving as medical
director, Dr. Leibovich is also responsible
for developing the Med Flight Program
at Baptist, and he regularly makes
helicopter flights to trauma scenes.

Dr. Leibovich has been working at
Baptist Medical Center since 1978. He
received his undergraduate degree from
Memphis State University and medical
degree from Meharry Medical College in
Nashville, Tenn. He completed a
rotating internship at the University of
Arkansas for Medical Sciences in Little
Rock.

In his spare time, Dr. Leibovich likes
to run — about eight to 1 2 miles every
other morning — and spend time with
his wife and four sons. ■

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Number 12

June 2001 • 411

MVb'iVJ ;l=VJ^hiL«KB

Postoperative Care —
Inattentive Approach

J. Kelley Avery, MD

In cases of
this type,
time and time
again it
appears that
the highest
standard of
care was
maintained
during the
operation,
but the
postoperative
care was not
up to the
expected
standard.

Case Report

A 17-year-old unmarried woman who had
experienced an entirely uneventful prenatal
course began to have labor about a week later
than her calculated due date. On examination,
her physician, a hoard certified Oh/ Gyn, found
her fetus to be presenting in the breech position.
Indications for the surgery were that the woman
was nulliparous at the end of her 41st week of
gestation, and that the baby was a breech
presentation. The presenting part remained high
after two hours of good labor, and a cesarean
section was recommended and carried out,
resulting in the delivery of a 6 pound 7 ounce
female infant with APGAR scores of 10 and
10. About two hours after the delivery, the
patient began shaking uncontrollably, and the
nurses said in the notes that she “demanded
something to stop the shaking” and that she was
“easily upset and crying.” The physician was
notified and ordered blood work for early
morning.

The patient’s admission WBC count had
been 15,300/cu mm with 76% neutrophils, not
unusual for this time in gestation, but the results
of the work done about three hours after delivery
was WBC count 25,200/cu mm with 95%
neutrophils (bands 16%). This was
postoperative day one. She continued to
complain bitterly of pain, and was described in
the nursing notes as “Patient hysterical/crying.”

The physician ordered an intravenous broad
spectrum antibiotic, Mefoxin. Blood cultures
were ordered X 2. Tylenol was given for pain
and the shaking. At midnight the temperature
was recorded at 101.4°F. The dressing was
removed and the wound was said to be “healing
well.” That morning she was moving about some
and seemed to be having less pain, but by the
afternoon of day two she complained of severe
right shoulder and back pain. The Mefoxin was
increased from 1 gm every eight hours to 2 gm,
and Clindamycin 600 mg every six hours IV was
added.

In the late afternoon the patient began to
complain more of pain and her abdomen was
found by the nurses to be “hard and distended.”
On walking, she expelled some gas from the
“stomach” with some relief of pain. Just before
midnight the dressing was removed and the skin
around the wound was found to be red.
Temperature remained 1 0 1 . 2 °F. Two hours later
the patient vomited, and the dressing was found
to be stained with a considerable amount of foul-
smelling, greenish-brown liquid. The physician
was notified and ordered more narcotic for the
pain. This was the third postoperative day.

The foul-smelling drainage continued in
increasing amounts. An enema gave “fair
results.” X-rays of the chest and abdomen were
ordered. The patient was made aware of the tests
that had been done and the X-rays that had been
ordered. She was also told that the physician
would come and examine her and discuss the
laboratory findings. The patient did not want
family called at this time. The progress note
indicated that the foul smelling liquid drainage
continued and that the abdomen appeared softer
but still distended.

The X-rays reported some free air under the
diaphragm, which was not considered abnormal
for this time after surgery. However, the film of
the abdomen showed multiple fluid levels and
suggested to the radiologist that intestinal
obstruction might be present, hut he added that
it could be due to a sustained ileus after surgery.
Mid-morning stat laboratory results showed
WBC count of 15,400/cu mm with 82%
neutrophils and 8% bands. The potassium was
reported as 3.2 mEq/L.

A progress note by the attending physician,
“Open surgical wound and clean,” was entered
in the record. A consent form was signed and
the attending physician took the patient to
surgery, opened the wound and irrigated it with
copious amounts of saline and Ringer’s solution.
The incision was left open to heal by secondary
intention. The operative note stated that the

412* The Journal

Volume 97

fascia was found to be intact except for
a small defect at the left extremity of
the lower abdominal incision.

The patient continued to vomit
following debridement and the
attending physician asked for a surgical
consultation “in the AM regarding
ileus.” An attempt was made to rectify
the electrolyte imbalance, particularly
in view of the persistent hypokalemia.
The patient continued to vomit. She
was responsive but having severe pain
in the abdomen. Late on the fourth
postoperative day Gentamycin was
added to the intravenous antibiotic
regimen.

The surgical consultant reviewed
the case in his note and speculated that
the hypokalemia was contributing to
the ileus. His opinion was that the
patient had an intra-abdominal abscess.
He suggested an aggressive attempt to
correct the potassium level. This was
attempted for the next 1 2 hours. When
the surgeon changed the dressing the
next morning, greenish liquid and gas
were escaping from the abdomen, which
suggested the presence of a small bowel
fistula with obstruction, and he
transferred the patient to the medical
center.

At the medical center the patient
was explored again, disclosing severe
suppurative peritonitis, a small bowel
perforation and some necrosis of the
abdominal wall in the region of the
initial transverse incision. The
perforation was closed and the
abdominal wound was packed open to
heal secondarily. Early in her stay in the
hospital in the medical center, she
developed severe adult respiratory
distress syndrome and required tracheal
intubation for about two months with
aggressive medical and nutritional
support. She was in the medical center
hospital for about five months. She
suffered severe neurologic deficits, both
motor and sensory, which largely
cleared with time and extensive and
intensive physical therapy.

A lawsuit was filed charging the
attending physician with negligence in
injuring the bowel at the time of the
cesarean section and failing to detect
and treat the injury in a timely manner.

This patient had medical expenses of
about $500,000 by the time she was
discharged from the medical center
hospital. The amount of the settlement
is confidential but it can be said that
the lawsuit was for an amount far in
excess of this physician’s policy limits,
but settlement was reached within that
limit.

Loss Prevention Comments

In cases of this type, time and time
again it appears that the highest
standard of care was maintained during
the operation, but the postoperative
care was not up to the expected
standard. In this case under the
expected standard of care the injury to
the bowel would have been discovered
earlier, perhaps 48 hours earlier. Injury
to adjacent structures during an
operation is not, in itself, a deviation
from the standard of care. With the
best of techniques and in the finest of
hospitals, this type of injury occurs.
Usually it is discovered immediately
after the fact, and corrective action
taken. Even when it is not discovered
immediately and when the record
supports careful postoperative scru-
tiny, the complication is found early
enough to take remedial action and
avoid serious injury to the patient. It is
when the record of the postoperative
care suggests inattention to detail,
failure to listen to the patient’s com-
plaints, and slow response to symptoms
of the complication, that the
physician can be adjudged negligent
in a court trial.

In this case, there was suggestive
evidence of problems as early as the
first postoperative day. The patient
was experiencing inordinate pain for
the type surgery she had. The nurses
talked in their notes of “hysteria and
crying” as if to dismiss the patient’s
complaints. There was some fever, not
unusual in the early postoperative
period, but the marked elevation of
the WBC count and the marked shift
to the left in the differential should
have been a high index of suspicion
that things were not going well in this
patient’s abdomen. Severe pain
persisted and late in the second day

there was some redness and edema
around the incision and over the pubic
area. This should have warranted a
more vigorous response from the
attending physician. The appearance
of foul copious drainage on the third
day after the operation and the nursing
note that described “gas from the
stomach” should have been
thoroughly investigated. Was the gas
coming from the rectum or the
“stomach? The answer to this question
probably would have called for front
abdominal exploration. This occurred
during heavy antibiotic coverage, and
certainly meant that the caregivers
were dealing with more than a skin
infection at the operative site. At this
point if there had been an aggressive
surgical response, with opening of the
incision including the peritoneum, the
injury to the small bowel would have
been discovered and repaired, leading
to recovery with only a few extra days
of hospitalization.

It was the delay in exploration of
the abdomen that led to the life-
threatening complications that
occurred later: the adult respiratory
distress syndrome, the necrotizing
myofascitis of the abdominal wall, the
cortical injury both cognitive and
motor and the prolonged hospi-
talization. One could take the position
that this patient is extremely lucky to
be alive, and that is true, but it was
the failure to observe carefully the
postoperative course that threatened
her life in the first place. The
operation is not over when the patient
gets back to her room. It requires the
continued attention of the physicians
to the complaints and daily progress
of the patient. When all that goes well
in the postoperative period, then, and
only then, is the surgery over. ■

Reprinted from a February 2000 issue
of Tennessee Medicine. The Case of the
Month is taken from actual Tennessee
closed claims. An attempt is made to
fictionalize the material in order to inake it
less easy to identify. If you recognize your
own case, please be assured that it is
presented solely for the purpose of
emphasizing the issues presented.

Number 1 2

|une 2001 • 41 3

RADIOLOGY

Posterior Dislocation of the Shoulder
is Uncommon, Hard to Diagnose

AUTHORS: Ronald Walker, MD — John O. Bethel, MD
AUTHOR/EDITOR: Steven R. Nokes, MD

Figure la. AP shoulder

History

A 50'year-old male presented to the emergency room
with shoulder pain and restricted motion after reaching to
turn oft his alarm clock in the morning. A shoulder series was
ordered (Figure la & h) followed hy a CT Scan (Figure 2).

Findings

The AP view reveals internal rotation of the humeral
head, a positive rim sign and a trough line. The first two are
indirect signs of a posterior shoulder dislocation. The scapular
Y-view demonstrates posterior displacement of the humeral
head, which lies beneath the acromion. The CT Scan
confirms posterior dislocation of the humerus with a J-shaped
defect in the medial anterior humeral head, with the posterior
margin of the defect perched against the posterior glenoid.

Discussion

The primary difficulty with posterior dislocation of the
shoulder is in making the diagnosis. Over half of the cases
are missed at the initial examination, with delay in diagnosis
of weeks to months. The continued pain and limited motion
are often misinterpreted as adhesive capsulitis or a frozen
shoulder, making this a common source of litigation.

Multiple factors contribute to overlooking this injury.
Posterior dislocation of the shoulder is uncommon,
accounting for only 3% of shoulder dislocations. The findings
on conventional radiographs are often subtle and indirect.
Lastly, the physician may identify a lesser tuberosity fracture

Figure 1b. Scapular Y-view

414 • The Journal

Volume 97

Figure 2. CT Scan of the shoulder

ARCHITECTURE

FOR TOUR MJDICAL NSSDS

I 300 764 ASTI

William Henry Asti, AIA

architects, economists, development amsultants

and fail to detect the underlying
dislocation (satisfaction of search).

Convulsive seizures are the most
common course of posterior shoulder
dislocation, followed by direct trauma.
A small percentage of cases are
spontaneous, as in our case.

The radiographic findings of
posterior shoulder dislocation are subtle
on the anterior posterior view, which is
usually sufficient to diagnose traumatic
shoulder injuries. Fixed internal rotation
is always present. When the humeral
head is posteriorly dislocated, it is pushed
laterally by the posterior glenoid,
producing apparent widening of the
joint space. A distance of greater than 6
mm from the medial humeral head to
the anterior glenoid rim is termed the
“rim sign.” This distance is 10 mm in
the case (figure la). The “trough line”
may be the only specific indication of
the posterior dislocation on the AP view.
This is an additional line running
vertically through the medical humeral
head corresponding to the trough'like
impaction fracture.

If detected early, posterior
dislocation is treated satisfactorily with
simple reduction in the absence of a
posterior glenoid fracture. A CT is
mandatory to exclude this. When a
delay in diagnosis occurs, surgery is
usually required because the capsule is
stretched and the humeral head defect
enlarges with time. ■

Drs. Walker and Nokes are with the
Radiology Consultants of Little Rock. Dr.
Bethel is the director of emergency medicine
at Baptist Memorial Medical Center in
North Little Rock.

References

1. Arndt, J.H., Scars A. D. Posterior
dislocation of the shoulder. AJR 1965,
94:639.

2. Cistemino, S.T., Rogers, L.F., S51.
Stufflebaum, B.C., Konglik, A.D. The
trough line: a radiographic sign of
posterior shoulder dislocation. AJR
1978, 130:951.

3. Rogers, L.F. Radiology of Skeletal
Trauma 2nd edition, Churchill,
Livingstone, Inc. 1992, 732-740.

Healthcare Resources

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www.medplusquotes.com
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MLS@medplusquotes.com

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Number 1 2

june 2001 * 415

ffl C a S E MONTH

Nasal Meningioma:
Report of One Case and Review

David L. Hatfield, MD — Mark White, MD — C. Araoz, MD

Abstract

A case of primary nasal meningioma in a 69-year-old
women is described. The pathologic, radiologic and clinical
characteristics are described. A summary of previously
published articles on the subject is given.

History

The patient is a 69-year-old female who presented with
complaints of right sided nasal obstruction for several months
duration. She had no complaint of pain, bleeding or drainage
related to her nose. She had non specific complaints of
headaches for years. Her past history is remarkable for
adenocarcinoma of the lung with metastatic disease to the
low neck nodes which had been treated with in the year prior
to her presentation with chemotherapy. Her history also
included excision of a parathyroid adenoma and thyroid gland
for benign disease.

Physical findings included a large polypoid grayish-red mass
which filled the right nasal cavity anteriorly except for a small
portion along the floor of the nostril.

Figure 1. Coronal CT section demonstrates right nasal
cavity mass displacing middle turbinate (black arrow) and
inferior turbinate (white arrowhead).

Radiology

CT scan in the coronal plane demonstrated a mass
extending from the medial superior nasal cavity in the area of
the cribiform plate displacing the middle and inferior turbinates
laterally. The ethmoid bulla was also opacified but did not appear
to be contiguous with the mass. No intracranial lesions were
seen and the bone of the base of the skull was intact. (Figures 1
and 2).

Preoperative Diagnosis

Intranasal mass with chronic ethmoid and maxillary
sinusitis.

Operative Findings

Under general anesthesia, endoscopic evaluation revealed
that the mass was firm and mobile. A needle aspiration yielded
no fluid or blood. A biopsy of the mass was obtained and
following frozen section the entire mass was resected via the
intranasal route with endoscopic guidance. The mass was found
to be attached to the anterior base of the skull medial to the

Figure 2. Mass causes partial erosion of perpendicular plate
(white arrowhead).

41 6 • The Journal

Volume 97

middle turbinate where the perpendicular plate of the ethmoid
fuses with the skull base. Minimal bleeding was encountered.
No CSF leak was produced. The patient was discharged from
the outpatient facility and made an uneventful recovery.
During a follow up period of more than eight months no
recurrence has been discovered.

Pathology

The diagnosis was intranasal meningioma. The tumor was
covered hy respiratory mucosa. The immuno-reactivity of the
tumor cells was positive for epithelial membrane antibody.
The cells did not react with desmin, cytokeratins, S-100 and
factor VIII antibodies.

Discussion

Extracranial meningiomas have been documented in the
car, temporal bones, skin, orbit and paranasal sinuses. Some
of these cases represent direct extension from an intracranial
meningioma. Reviews by Ho1 , Perzin2 and Taxy3 published in
1980, 1984 and 1990, respectively, examined tme primary
nasal and paranasal sinus meningiomas. The cumulative total
of published cases by various authors is about 30 cases. A recent
review by Thompson LD and Gyure KA from the Armed
Forces Institute of Pathology4 found 14 intranasal
meningiomas between 1972 and 1992.

Nasal meningiomas have occurred at all ages with the

mean at about 47.6 years. Some series show a female
predominance of 2.5:1. The pathogenesis of intranasal
meningiomas is uncertain. They are thought to arise from cells
of the arachnoid villi which were pinched off during embryonal
development at ectopic sites. Presenting symptoms of nasal
meningiomas include nasal obstruction, epistaxis, sinusitis, pain,
mass, nasal discharge, or rarely, anosmia. Nasal meningiomas
are almost always benign, but they can cause damage to
surrounding structures by mass effect or erosion through bone.
Complete surgical excision is the treatment of choice.
Recurrence is rare but can occur from incomplete excision.
Complications of surgical excision include CSF leak, blindness,
double vision, bleeding and anosmia. ■

References

1 . Ilo, K.L. Primary meningiomas of the nasal cavity and
paranasal sinuses. Cancer 1980,46: 1442-7.

2. Perzin, K.H. Pushparaj, N. Non-cpithelial tumors of the nasal
cavity, paranasal sinuses, and nasopharynx: a
clinicopathologic study Cancer 1984-1 54: 1860-9.

3. Taxy, K.H. Meningioma of the paranasal sinuses. American
Journal of Surgical Pathology 1990; 14: 82-6.

4. Thompson, L.D., Gyure, K.D. Extracranial smonasal tract
meningiomas; a clinicopathologic study of thirty cases with
a review of the literature. American Journal of Surgical
Pathology 2000 May-, 24(5): 640-50.

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Number 12

June 2001 • 417

Arkansas Foundation
for Medical Care

U A L B T Y

EDITORIAL PANEL: WILLIAM E. GOLDEN, MD; DEBORAH L MARPLE, RN, BS, CPHQ;

DONNA S. WEST, PHD

Enhancing Patient Safety
Preoperative Antibiotic Prophylaxis

BY DONNA S. WEST, RPH, PHD,
WILLIAM E. GOLDEN, MD AND
NENA SANCHEZ, MS

Postoperative wound infections
occur in approximately 5% of
all patients who undergo
surgery, costing the health care
system an additional $1 billion
annually.1,2 Fortunately using
prophylactic antibiotics prior to
surgery has been shown to reduce
postoperative infections. More
specifically, the timely
administration of prophylactic
antibiotics within two hours before
the initial incision can reduce the
risk of infection, resulting in
reduced length of hospital stays and
reduced hospital costs.

In an effort to improve patient
safety in Arkansas, AFMC has been
conducting a quality improvement
project focusing on the appropriate
use of perioperative antibiotics. Of
specific interest was the

administration and timing of the
initial antibiotic dose.

A retrospective chart review was
conducted. Five hundred sixty-nine
cases involving hip replacement
surgery, knee replacement surgery, or
aortofemoral popliteal bypass/other
vascular shunt surgery were randomly
selected from 37 hospitals statewide.
In all three surgical procedures,
antimicrobial prophylaxis is needed.
Data regarding surgical start times
and the timing and administration of
antibiotics were abstracted from the
patient charts. Of the 569 cases, 531
cases met the denominator criteria.

The results indicated that
approximately 80% of patients
received prophylactic antibiotics
within the two-hour time window, as
shown in Table 1. Alternatively, this
success rate can he stated as a failure
rate. Of the selected patients, 20%
did not receive antibiotic therapy
within the two-hour window: 10%
failed to receive any prophylactic

antibiotic and 10% failed to receive
the prophylactic antibiotic within
the two-hour window.

Quality improvement initiatives
often follow a S-shaped curve; thus,
improving the last 10 or 20% is often
difficult. However, efforts need to be
made to increase the timely
administration of prophylactic
antibiotics.

The results reveal areas where the
process of administering prophylactic
antibiotics can he improved. For
example, prophylactic antibiotics
administered on the wards were more
likely to fall outside of the two-hour
window. Table 2 provides the average
time between the administration of
the prophylactic antibiotic and the
initial incision, based on the location
of administration. It is evident that
the probability of receiving
prophylactic antibiotic therapy
within the two-hour time period is
greatest when given in the operating
room.

Table 1: Rates of Antimicrobial Prophylaxis within Two-Hour Window

Procedure

Compliance

(%)

Hip or Knee Replacement

332

276

(83.1)

Aortofemoral Popliteal Bypass/ Other Vascular Shunt/Bypass

199

150

(79.4)

Total 531

426

(80.2)

418 • The Journal

Volume 97

U A L I T Y

Table 2: Rates of Antimicrobial Prophylaxis Within
Two-Hour Window Based on Location of Administration

Location of

Rate within Two-Hour Window

Administration

If Pre-op Antibiotic Given

96.63%

83.33%

OR Holding

88.10%

Ward

64.29%

These results support the quality
standards of the Infectious Disease
Society of America published in
Clinical Infectious Diseases as well as
other antibiotic prophylaxis
guidelines.3 Several solutions
designed to deliver prophylactic
antibiotics in a more timely fashion
have been recommended, as stated
below.4

“Each hospital (should) set up a
system that makes someone
responsible for making certain that
antibiotics are given at a certain time
in a routine fashion.... Assigning the
circulating nurse to check the box
and make sure it has been done will
ensure that it will happen.”4

Likewise, it has been
recommended that prophylactic
antibiotics for surgery be dispensed
directly to the anesthesiologist or
CRN A and have the
anesthesiologist deliver the
antibiotic as part of the routine
patient care. Administration of
prophylactic antibiotics on the
patient wards should be eliminated.

The study results also provide
insight into the types of antibiotics
being used for antimicrobial
prophylaxis. Not surprising,
cefazolin was used in 71% of cases
receiving antibiotics, which is in
compliance with perioperative
antibiotic guidelines.5,6'7 The most
troubling result was the number of
patients who received vancomycin
as a routine order for antimicrobial
prophylaxis. Approximately 11%

(61 cases) received vancomycin. Of

these 61 cases, 64% (39 cases)
received vancomycin because of a
routine order. For seven (11%) of
these cases, vancomycin was given
because of patient allergy or to target
against resistant organisms; and for
12 (20%) of the cases, the reason
vancomycin was given is unknown.

Textbooks, guidelines and journal

It has been recommended
that prophylactic
antibiotics for surgery be
dispensed directly to the
anesthesiologist or CRN A
and have the anesthe-
siologist deliver the
antibiotic as part of the
routine patient care .
Administration of pro-
phylactic antibiotics on the
patient wards should be
eliminated.

articles warn that first-line drugs
such as the fluoroquinolones, third-
generation cephalosporins,
imipenem and vancomycin should
not be used for prophylaxis because
this may compromise their
effectiveness in treatment. 6,7,8 First-
or second-generation cephalosporins
have been shown to be effective in

prophylaxis, and the more potent
first-line agents should be reserved
for use as treatment of presumed or
established infection. It is
recommended that hospitals
reevaluate their use of vancomycin as
a standard order for antimicrobial
prophylaxis.

Overall, increasing the timeliness
and appropriateness of antibiotic
prophylaxis in surgical procedures will
reduce postoperative wound infection
rates and lower health care costs.
Targeted interventions regarding the
timing of the use of prophylactic
antibiotics is likely to reduce wound
infections, resulting in improved
patient care and decreased health care
costs. As health care professionals
focus on patient safety, system
improvements in all areas, including
antimicrobial prophylaxis in surgery,
will be necessary. ■

References:

1 . Gottrup F. Prevention of Surgical Wound
Infections (editorial). N Engl J Med
2000; 342(3): 202-203.

2. Wenzel RP. Preoperative Antibiotic
Prophylaxis (editorial). N Engl J Med
1992; 326:337-339.

3. Infectious Diseases Society of America.
Quality Standard for Antimicrobial
Prophyalxis in Surgical Procedures. Clin
Infect Dis 1994; 18(3): 422-427.

4- Panel Discussion. Current Trends in
Antibiotic Prophylaxis in Surgery.
Surgery 2000; 128: S 14-SI 8.

5. ASHP Commission on Therapeutics.
ASHP Therapeutic Guidelines on Anti-
microbial Prophylaxis in Surgery. Am J
Health-Syst Pharm 1999; 56: 1839-1881.

6. Page CP, Bohnen J, Fletcher R,

McManus AT, Solomkin JS, Wittman
DH. Antimicrobial Prophylaxis for
Surgical Wounds. Arch Surg 1993;
128:79-88.

7. Woods RK and Patchen D. Current
Guidelines for Antibiotic Prophylaxis of
Surgical Wounds. Am Family Physician
1998; Available at http://www.aafp.org/
afp/980600ap/woods.html, Accessed 7-
28-2000.

8. Centers for Disease Control and
Prevention. Guidelines for Prevention of
Surgical Site Infection. Am J Infect
Control 1999; 27(2): 97-132.

Number 1 2

June 2001 * 419

SCIENTIFIC ARTICLE

Common Urologic Problems In Children:
Guides To Evaluation And Referral, Part I

John F. Redman, MD — Pramod P. Reddy, MD

Abstract

A discussion of common urologic problems in children is
presented to provide primary physicians with appropriate
guidelines for evaluation and referrals. The problems
will be discussed in two parts: Part I will cover
urinary tract infections, voiding dysfunctions,
hematuria and proteinuria. Part II will cover
abnormalities found on antenatal renal
ultrasonography, hypospadias and other
penile anomalies, phimosis, undescen-
ded testes, inguinal hernia and hydro-
cele, and varicoceles.

An adage states: “The questions
in medicine never change over time
— only the answers.” Certainly the
busy primary care physician may
experience the frustration of changing
evaluation guidelines established by
narrow subspecialties. Guidelines for the
evaluation of children with disorders of the
genitourinary tract are no exception. The
following presentation will address some of the most
common childhood urologic problems with a brief discussion
of how to evaluate and when to refer for pediatric urologic
consultation or management.

Urinary lYact Infections

By the broadest definition, urinary tract infections would
include infections of the kidneys, bladder and urethra. The most
common infections are those caused hy bacteria. Usual
symptoms include dysuria, frequency, urgency, daytime wetting,
suprapubic discomfort, flank discomfort and fever. Although
all of these symptoms may be associated with a urinary tract
infection, a child may have all of these symptoms and not have
an infection of the urinary tract. Further, young children and
infants may have urinary tract infections and have no symptoms
directly attributable to the urinary tract.

The key to diagnosis is the urinalysis. The urinalysis,
however, is only valid if the urine submitted for analysis has been
collected in such a manner as to preclude contamination. The
easiest collection is in circumcised males who are old enough to
void on command. If urethral complaints are present, it is useful
to have the boy, in addition to collecting a mid-stream specimen,
collect the initial lOcc to obtain a urethral wash. An uncircum-

cised male should retract the prepuce to the extent that the
meatus is uncovered. With boys too young to void on command,
the genitalia may he cleansed and the urine collected in an
adhering plastic bag (wee-bag). Bagged urine
specimens, however, are frequently unreliable
because of bacterial contamination.
Atraumatic catheterization using a small
infant feeding tube (5-8F) may be
required to assure an uncontaminated
collection.

In infants, a suprapubic aspiration
of the bladder may be perfonned to
avoid catheterization if questions
remain regarding the adequacy of the
collection.

In girls who are able to void on
command, there is seldom a reason to
resort to the use of a catheter to obtain
urine for examination and culture. A
helpful technique is to have the child sit
astride the commode with the mother kneeling
beside her. The mother separates the child’s labia and
collects the specimen in mid-stream. The technique may result
in wetting of the hands and floor, hut the accuracy of the
collection is confinned hy the mother so that any abnormal finding
will not later be attributed to a less than optimal collection. In
girls unable to void on command, an adhering plastic collection
bag may be utilized. However, if an abnonnal urinalysis results, it
should be confirmed by catheterization using a small infant feeding
tube ( 5 or 8F) . Although a reagent-impregnated test strip is helpful
in screening for bacteria and pyuria, a microscopic examination
of the centrif uged sediment should be perfonned for confirmation.

In a child with a properly obtained urine specimen, any
bacteria is significant. The finding of pyuria and bacteria
confirms a urinary tract infection. Whether bacteria are noted
or not, with pyuria, the urine should be submitted for culture.
If a child has signs or symptoms indicative of a urinary tract
infection, the urine should probably be cultured since small
amounts of bacteria may be missed with urinalysis alone.

Occasionally bacteria without pyuria will be found, which
may indicate colonization but not an infection. It is incalculable,
however, how many girls are treated and evaluated for urinary
tract infections, unnecessarily, based on the findings from
improperly collected urine specimens.

420 • The Journal

Volume 97

Any child with an initial documented urinary tract infection
is deserving of an evaluation, which should include
ultrasonography of the kidneys and bladder and a voiding
cystogram. All males should be evaluated with a contrast voiding
cystourethrogram. In females the initial cystogram may he done
using contrast media or a radiopharmaceutical agent.

When to refer

The primary reasons to consider referral are the findings of
anatomic abnormalities of the urinary collecting structures or
vesicoureteral reflux. Although children with the lesser grades
of reflux are usually managed medically, many primary care
physicians still prefer at least an individualized or case-by-case
opinion regarding an appropriate regimen for management. If
an initial referral has not been sought, it should be strongly
considered if the child has break-through infections on
maintenance antimicrobial prophylaxis.

Voiding dysfunctions

There are a myriad of manifestations of childhood voiding
dysfunctions including nocturnal enuresis, diurnal and nocturnal
enuresis, frequency, urgency, infrequent voiding and intermittency
of the urinary stream. There is also a wide range of ages when
children normally have attained both daytime and nighttime
urinary continence. At age 4 the majority of children will have
daytime and nighttime continence. However, by age 5, 10-15%
of children may still have nocturnal enuresis.

For children presenting with symptoms of voiding
dysfunction, a screening urinalysis can be a timesaver. If the
urine shows bacteria and pyuria on a well-collected clean catch
aliquot, the child should be evaluated as in the case of any child
with a urinary tract infection. If the urine is clear microscopically,
a further history should be obtained to include, in addition to
urinary complaints, a bowel history, particularly that of
constipation and/or encopresis.

In boys the urethral meatus should be examined. In both
boys and girls a history should be obtained regarding a small
urinary stream, straining with voiding, or infrequent voiding.
In all children the skin over the lumbar spine, sacrum and
coccyx should be inspected for signs of an underlying spinal
dysraphism, such as deep dimpling or a patch of hair. All
children brought to the attention of a physician with a voiding
dysfunction should undergo an ultrasound examination of the
kidneys and bladder.

When to refer

Referrals should be done at any point that the physician is
unclear as to the diagnosis of a voiding dysfunction, does not
have a management plan or the child is not responding to a
management format. Children with an abnormal renal and
bladder ultrasound examination should be referred.

Hematuria

Hematuria may he gross or microscopic. A frequent concern

of primary care physicians is the finding of blood in the course
of a routine urinalysis as part of a well-child examination. One
of the most common concerns is a colorometric change
indicating the presence of blood on one of the commercial test
strips. Often this finding is of little consequence. However, it
should he confirmed with a microscopic examination of the
sediment obtained by centrifuging the urine. If blood is
identified microscopically, then further evaluation should be
by an ultrasound examination of the kidneys and bladder. An
excretory urogram (I VP) and endoscopy of the bladder are
not necessary in children in the initial evaluation of hematuria.

Gross hematuria should be evaluated by careful
examination of the centrifuged urine sediment to look for casts
and bacteria. The history of the actual visualization of blood
in the act of voiding is important in boys, that is, was the
blood noted at the first, the last or all through the stream?
Blood noted at the first and the last of the stream suggests a
urethral site for the bleeding. Other important points in the
history are the presence or absence of clots and the color of the
urine, whether dark, bright red, maroon or brown. Discomfort
with voiding may be an important fact as well as a history of
any pain associated with the onset of hematuria. These signs
and symptoms alone may not be significant, hut coupled with
other findings may aid in establishing a correct diagnosis. A
child with gross hematuria also should he evaluated with
ultrasonography of the kidneys and bladder.

When to refer

Hematuria thought to be secondary to renal parenchymal
disease may be a reason for referral to a nephrologist if the
physician is not sure of the diagnosis or wishes assistance with
evaluation and treatment. Patients with calculus disease should
be referred for further evaluation regarding etiology of the calculi
and especially if there is evidence of obstruction. Any abnormality
of the renal parenchyma or collecting structures or bladder noted
on ultrasonography should be evaluated by a urologist.

Proteinuria

Proteinuria as an isolated finding should be managed by
surveillance. Persistent proteinuria should he evaluated by renal
ultrasonography. Proteinuria in the higher ranges (3-4 + )
particularly when associated with abnormal urine sediments,
such as red blood cells and casts, strongly indicates glomerular
disease.

When to refer

Children with persistent proteinuria or heavy proteinuria,
particularly that associated with abnormal urinary sediments,
should be referred to a nephrologist for further recom-
mendations. ■

Drs. Redman and Reddy are with the department of urology,
University of Arltansas College of Medicine and Arkansas Children’s
Hospital.

Number 1 2

June 2001 • 421

PEOPLE + EVENTS

EVENTS

College of Medicine
Alumni Reunion
Weekend

The annual College of
Medicine Alumni Weekend
hosted by the Arkansas
Caduceus Club is scheduled
for June 8-10 at the Capital
and Excelsior hotels in
Little Rock. Returning
graduates from the follo-
wing classes may parti-
cipate: 1936, 1941, 1946,
1951, 1956, 1961, 1966,

1971, 1976, 1981, 1986 and
1991. Activities will kick off
with a reception June 8 at
the Capital Hotel honoring
those who graduated 50 or
more years ago. Also that
night, the annual awards for
Distinguished Alumnus and
Distinguished Faculty will
he presented at a banquet in
the Excelsior Ballroom.
Activities on June 9 will
include a scientific session
on the campus of UAMS,
tours of the new facilities, a
luncheon and the annual

meeting of the alumni
association. In addition,
there will be separate dinners
for each graduating class at
the Capitol and Excelsior
hotels that night. Conclu-
ding the weekend’s activities
will he a family brunch on
June 10.

More information about
the event, as well as nom-
ination forms for the Distin-
guished Alumnus and Dis-
tinguished Faculty awards,
may be obtained hy calling

(501) 686-6684.

HONORED

AMA Recognizes
Fort Smith Physician
as Emerging Leader
in Medicine

Dr. Hugh H. Jackson of

Fort Smith was among a
select group of 50 practicing
physicians chosen to parti-
cipate in an intensive train-
ing program designed to
sharpen the political and
advocacy skills of emerging
leaders in medicine. Spon-
sored hy the American

New Members

Ossama Al-Mefty, MD

NS - Little Rock

Roger Amick, MD

P - Little Rock

Elizabeth Armstrong, MD

GP - McCrory

Paul A. Armstrong, DO

GS - Van Buren

Samuel H. Arnold, DO

GS - Hope

Harendra Arora, MD

AN - Little Rock

Gregory J. Babbe, MD

FP - College Station

Robert R. Baker, DO

P - Van Buren

Peter H. Ball, MD

FP - Fayetteville

Jeffery L. Barber, DO

FP - Wynne

Bart Barlogie, MD

ON - Little Rock

Sandeep Bhargava, MD

GE - Little Rock

Joseph Bissett, MD

CD - Little Rock

James Bradburn, MD

OTO - Fort Smith

Daniel Bradford, MD

HEM - Fayetteville

Nita Brown, MD

CHP - Russellville

Derek M. Bryant, MD

FP - Little Rock

Dante R. Burgos, MD

P - Texarkana

William J. Burt, MD

FP - Fort Smith

James I. Cagle, MD

FP - Junction City

Maida P. Campanini, MD

PD - Hot Springs

Douglas T. Campbell, MD

PD - West Memphis

Patrick D. Chan, MD

NS - Searcy

Lori M. Cheney, MD

IM - Mountain Home

Joel Cobb, MD

FP Resident - Little Rock

Saladin A. T. Cooper, MD

OBG - Little Rock

Witold P. Czerwinski, MD

P - Batesville

David G. Davenport, MD

DR - Little Rock

Roy E. Denton, MD

IM - West Memphis

Jonathan Drummond-
Webb, MD

CDS - Little Rock

Uma Duvvuri, MD

IM - Jonesboro

Vernon L. Eagan Jr., MD

AN - N. Little Rock

Andrea J. Eberle, MD

PD - Little Rock

Michelle L. Eckert, MD

GS - Pine Bluff

Michael A. Eckles, MD

IM Resident - Little Rock

David M. Evans, MD

CD - Searcy

Amanda Ferrell, MD

IM Resident - Little Rock

James W. Fletcher III, MD

EM - Jonesboro

Jason Foster, MD
PD - Springdale

James H. France, MD

U - Conway

Elizabeth A. Frazier, MD

PDC - Little Rock

Charles M. Friedman, MD

R - Little Rock

Venkatarama R.

Gaddam, MD

Resident - CD Little Rock

William P. Galli, DO

IM - Mountain Home

John D. Gaston, MD

FP - Fayetteville

Sunil Gera, MD

AN - Jonesboro

Ira Gershner, MD

IM - N. Little Rock

Gunnar H. Gibson, MD

D - Little Rock

Stephanie L. Granger, MD

GS - Little Rock

Russell J. Green, MD

OM - Lowell

Paula M. Guinnip, MD

GS - Searcy

Marc Gunter, MD

OBG - Hot Springs

Arun K. Gupta, MD

IM - Newport

Holly H. Handloser, MD

FP - Little Rock

Ali M. Hashmi, MD

P - Jonesboro

May Hawawini, MD

PD - Little Rock

Deborah A. Hays, MD
FP - Fort Smith

Prabhat K. Hebbar, MD

IM Resident - Little Rock

422 • The Journal

Volume 97

Medical Association
and GlaxoSmith'

Kline, the Emerging
Leaders Develop-
ment Program pre-
pares physician lead-
ers to meet the
challenges of ad-
vancing health policy through the
legislative process. Dr. Jackson was
selected for the program based on his
demonstrated leadership potential,
commitment to leadership, parti-
cipation in organized medicine and
diversity of leadership experience. The
day-long program was held in con-
junction with the AMA’s National
Leadership Conference March 3-6 in
Washington, D.C.

Arkansas State University
Honors Team Physician

Dr. Glenn Dickson, an orthopedic
surgeon in Jonesboro and head team
physician for Arkansas State Uni-
versity’s athletic teams for the past 25
years, was honored for his service to
the university during a basketball
game Leb. 10. Among the services he
provides to the university’s athletics
programs are physical examinations of
the more than 350 student athletes and
weekly injury clinics and exams. He is
also on call and available when needed
hy the school. He is an honorary
member of the Southwest Athletic
Trainers Association.

Memorial Scholarship Fund
Established in Honor of Late
Physician

The North Arkansas College
Loundation Inc. has established a
memorial scholarship in honor of the
late Dr. Frederick C. Turner Jr. of
Mountain Home. The scholarship will
enable a student who has achieved
academic excellence to begin or
continue his or her postsecondary
education. Recipients may pursue any
course of study that will result in an
associate degree, licensure or certificate.
To obtain an application or for more
information, contact North Arkansas
College’s financial aid office at (870)
391-3240.

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Number 1 2

June 2001 • 423

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Pulaski County Medical
Society Officers Elected

The Pulaski County Medical
Society recently elected Dr. Anthony

D. Johnson, a
general pediatrics
practitioner with
the Arkansas Pe-
diatric Clinic, as
its new president.

Other officers in-
clude Dr. David

E. Bourne, pres-
ident-elect; Dr.

Denise R. Green-
wood, vice pres-
ident; Dr. Steven W. Strode, secretary;
Dr. Thomas L. Eans, treasurer; and Dr.
Samuel B. Welch, immediate past
president.

Dr. Johnson

Retiring Physician Honored
at Reception

Dr. Stan Teeter and his wife,
Maysel, greeted friends and patients
during a reception in their honor at the
Millard-Henry Clinic in Russellville
Feb. 18. Dr. Teeter retired after 36 years
of practicing medicine.

AWARDS

Physicians Receive Awards
from AMA

Each month the American Medical
Association presents the Physician’s
Recognition Award to those who have
completed acceptable programs of
continuing education.

AMA recipients for February are
Dr. Sameh Ramadan A. Abul-Ezz of
Little Rock, Dr. Hugh G. Donnell of
Rogers, Dr. Di Hou of Little Rock, Dr.
Christopher S. Johnson of Rogers, Dr.
James L. Jones of Fayetteville, Dr.
Anthony B. Junkin of Newport, Dr.
Abdul K. Kocer of Waldron, Dr. Lance
R. Lincoln of Mountain Home and Dr.
Andrew J. Lueders of Rogers.

OBITUARIES

H.N. Faulkner, MD

Dr. H.N. Faulkner, 75, died March

424 • The Journal

Volume 97

7 at his home in Helena. Born in
Wynne, Dr. Faulkner served in the
U.S. Navy during World War II and
practiced medicine in Helena for
more than 33 years.

He attended the University of
Southwestern Louisiana at Lafayette,
La., and graduated from the
University of Arkansas at Fayet-
teville. He graduated from UAMS in
1953 and completed his internship
at Emory University-Crawford Long
Hospital in Atlanta.

Dr. Faulkner was on the staff of
Helena Regional Medical Center
until his retirement in 1987, and
served as chief of staff in 1975. He
was a member of the Phillips County
Medical Society, Phi Chi Medical
Fraternity and Kappa Alpha
Fraternity.

He is preceded in death by his
father, H.N. Faulkner Sr.; his mother,
Georgia Bullard Faulkner; and his
sister, Wila Maxine Faulkner. He is
survived by his wife, Helen Martin
Faulkner; three sons, Robert N.
Faulkner of Alexander, William M.
Faulkner of Benton, Martin B.
Faulkner and his wife, Laurie
Faulkner of Dallas; one sister-in-law,
Mildred M. Jones and her husband,
Lloyd T. Jones of Horseshoe Bend;
and one granddaughter.

John A. Rollow III, MD

Dr. John A. Rollow III of
Bentonville died Feb. 8. Dr. Rollow
was raised in Wynnewood, Okla.,
and served in both France and Japan
during World War II. He completed
his residency at Wesley Hospital in
Oklahoma City and moved to
Bentonville in 1948. For several
years of his career, Dr. Rollow was
one of only two surgeons in Benton
County. He retired from his practice
as a general practitioner in 1988.
Throughout his career Dr. Rollow
delivered more than 3,000 babies. In
honor of his service to the
community, a surgical wing at Bates
Medical Center in Bentonville bears
his name.

He is survived by his wife, Mary. ■

W IMPROVING

Physicians

Bottom-line

Physicians
Management
Services, 7nc.

Keeping the practice of
medicine independent”

Coding

Billing

Receivable Management &
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Transcription

Scott McCall & Linda Cochran • 2909 Military Road, Benton, AR 72015
1-800-353-6165 • e-mail: pmsl 12291@aol.com • www.physiciansmgmt.com

Number 1 2

June 2001 • 425

Located in the heart of the beautiful Ozark mountains, the Mockingbird
Bay Resort is often referred to by its guests as the “closest lake resort to rivers”
because of its convenient location on Lake Norfork and its proximity to
crystal clear rivers.

Nestled among oaks, hickories, redbuds, dogwoods and mimosa pines,
each cabin has its own deck overlooking the lake and mountains. All uniquely
decorated, the cabins come equipped with everything you need for a relaxing
weekend getaway, including remote control TV/VCRs, radios, microwaves,
four-burner stoves with ovens, full-size refrigerators, coffee makers, toaster
ovens, cookware, dinnerware and utensils.

The resort is a favorite among families because of its abundance of
recreational activities for the children, including a treehouse, bonfire pit,
sandbox, playground, horseshoes, tetherball and a game room complete with
foosball, arcade games and more. Children and adults both love swimming in
the pool or off the sun deck. And for guests who prefer a real swim beach,
Sand Island, a popular public swimming spot, is located about a mile away.

In addition, the crystal clear water of Lake Norfork provides for some
excellent scuba diving. Many guests also enjoy sunbathing or jumping off of
“Jordan Bluffs,” spectacular, 15-feet bluffs that create a natural high dive into
water 70-feet deep.

At the end of the day, resort guests can unwind and cook dinner outside
on the Weber grills and have a relaxing picnic under the resort’s covered
pavillion.

Fishing is also a popular activity among the guests. The rivers that wind
through the resort’s mountains, such as the White River and the North Fork
River, provide world-class fishing for Rainbow, German, Brown and Cutthroat
trout, and the 30, 000-acre lake is known for its striped bass, white and black
bass, crappie, walleye and more. For boating enthusiasts, Mockingbird has a
carpeted boat dock with nine stalls and a wide selection of rental boats,
including two new pontoons, fishing boats and smaller boats. The resort also
has a pedal boat for guests to enjoy free of charge.

Perfect for larger families, the resort also has a lakehouse that can
accomodate up to 10 people. The 1,700-SF house has three queen beds, four
twin beds and a panoramic lake view and balcony.

Nearby attractions to the resort include Blanchard Springs Caverns, the
Ozark Folk Center, hiking and nature trails, restaurants, antique and craft
shops, horseback riding and more. ■

Daily summer rates for the cabins range from $73-$ 143, and weekly rates
range from $435-$855. Pets are not allowed at the resort.

Special Publications
Publisher
Brigette William

Special Publications
Editor- in -Chief
Natalie Gardner

Editorial Art Director
Irene Forbes

Advertising Art Director
Nikki Cruse

Photographer
Mark Wilson

Managing Editor
Shelby Brewer

Copy Editor
Abigail West Jumper

Editorial Assistant
Susan Van Dusen

Sales Manager
Stephanie Hopkins

Account Executive
Liz Earlywine

Director of Design
and Circulation
Virgeen Healey

Production and
Circulation
Coordinator
Jeremy Henderson

Advertising Coordinator
Kristen Heldenbrand

Marketing Assistant
M itzi Tiffee

Database Administrator
Andrea Martin

Advertising Assistant
Greg Duszota

A ARKANSAS BUSINESS
PUBLISHING GROUP

^ www.abpg.com

Chairman & Chief Executive Officer
Olivia Farrell

President and Publisher
Jeff Hankins

Executive Vice President
Sheila Palmer

Adhesive bandage, which plaintiff alleges
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©2000 St. Paul Fire and Marine Insurance Company
Coverages underwritten by St. Paul Fire and Marine Insurance
Company or another member of The St. Paul Companies
www.stpaul.com

Number 1 2

June 2001 • 427

Journal 2000-01 Index

OF THE ARKANSAS MEDICAL SOCIETY

Volume 97

Numbers 1-12

1999 was a Year to Regroup and
Refocus, 52
50-year Club, 56

A Baseline is Necessary, 97
A Higher Calling, 405
A Horrible System for Everybody, 277
Abel, Lee, 79, 331
Abdul-Ezz, Sameh R., 424
Ackerman, William E„ III, 111,401
Acott, Alison A., 392
Advocate Fatigue, 149
Akbar, Safdar Ali, 392
Akins, John R, 392
Albrecht, Tammy G., 256
Alderson, Roger Willis, 319
Alexiou, Jerry A., 354
Allergic Fungal Sinusitis Has Become
Common, 245
Allison, Russell B, 255
Al-Mefty, Ossama, 422
Al-Refai, Fareeda Ann, 256
Amick, Roger, 422
AMS Benefits, 383
AMS Budget, 375
AMS Council, 59, 368
AMS Efforts Defend Children’s Health
Care, 299

AMS Executive Vice President Report, 367
AMS House of Delegates, 61
AMS Medical Student Section, 384
AMS Supports Ban on Smoking in
Restaurants, 366

AMS’ Journal Has Taken on a More
Sophisticated Look, 155
AMS' Political Message Stays the Same, 1 53
Anaya, Carlos, 319
Ancalmo, Claudia M„ 392
Anderson, Charles, 287
Angtuaco, Edward E.C., 31
Anticoagulation Management in
Mechanical Heart Valve Patients Who
Undergo Dental Procedures, 128
Araoz, C.,416

Arkansas Behind on National Quality
Improvement Indicators, 163
Arkansas Department of Health, 387
Arkansas Health Care Access, 385
Arkansas Medical Foundation, 386
Arkansas Medical Society Long-range
Plan, 63

Arkansas Patient Safety Initiative, 349
Arkansas State Medical Board, 379
Arkins, James Henry, 319
Armstrong, Elizabeth, 422

Armstrong, Paul A., 422
Arnedall, Clarence J., 256
Arnold, James R„ 255
Arnold, Samuel H., 422
Arora, Harendra, 422
Arthur, David E„ 392
Ashbrooks, Darrin D„ 392
Ashley Jr., John D.,31
Atken, Mary, 351
Attwood, H.M., 391
Avery, J. Kelley, 19, 97,124,194, 241,
277,340,412

Babbe, Gregory J„ 422
Bacon, Lori Beth, 255
Bailey, Amy E„ 392
Bailey, Charles W„ 391
Baker, Clark M„ 68
Baker, Robert R., 422
Ball, Peter H„ 422
Ballard, Devon R., 135
Banken, Joseph, 164
Banning, Michelle S„ 256
Barber, Jeffery L., 422
Barker, Lisa R„ 392
Barlogie, Bart., 422
Beck II, Joseph M., 31, 149
Beck, Jason D., 392
Beckham Creek Cave Haven, 174
Behind-the-Scenes Legal Work Provided
AMS Members, 188
Behrens, Bing X., 256
Belk, Robert J., 135
Bercher, Daniel Lance, 351
Berry, Marion, 55
Berry, Michael F., 256
Bethel, John 0., 414
Bhargava, Sandeep., 422
Bibbs, David L„ 392
Billie, James D„ 255
Bissett, Joseph., 422
Blanchard Springs Caverns, 137
Bledsoe, Samuel E„ 392
Bohra, Robin L, 392
Bonner, Jimmy D„ 391
Booth, Billynda L„ 392
Bourne, David E„ 424
Bower, Charles M„ 245
Bradburn, James., 422
Braden, Lawrence F„ 205
Bradford, Daniel., 422
Brainard, Jay 0., 391
Braswell, Leah E„ 392
Brewer, Shelby, 302, 335, 405
Brilliant Disguise, 79

Broach, Rolland F„ 354
Brown, Donna, 392
Brown, Nita, 422
Brown, Peggy J., 354
Brown, Scott P„ 392
Brownfield, Shannon H„ 256
Browning Sr., Donald G., 319
Brull, Sorin Jos, 66
Brummett, Carolyn, 389
Bryant, Derek M„ 422
Burba, Alonzo R, 346
Burgos, Dante R„ 422
Burnette, Hugh F„ 66
Burt, William J., 422
Burton, Frank M„ 67
Busby, James D„ 391

Cadle, Kimberly L„ 135
Cagle, James I., 422
Caldwell, Karen L., 206
Calhoun, Aris, 256
Campanini, Maida P., 422
Campbell, Douglas 1, 422
Campbell, Jenny, 392
Can Business & Science Coexist in this
Century, 401
Carroll, Peter J., 391
Carter, Sherri R„ 392
Casey, Sean P„ 392
Cassat, James E„ 392
Cawyer, John C., 392
Chambers III, Carlton L„ 62, 66, 185,
333, 377

Chambers, Sue, 90, 299
Chan, Patrick D„ 422
Chatelain, Stephen M„ 256
Cheney, Lori M., 422
Citty, Jimmy C., 391
Clark, Richard B„ 283
Cobb, Joel, 422
Cohagan, Donald L., 255
Coleman, Roy D„ 101, 205
Collins, Kenneth P., 101, 205
Collins, Vera Y., 256
Common Urologic Problems In
Children: Guides To Evaluation And
Referral, Part 1, 420
Congressman Champions Patients’
Rights, 55

Continuing Medical Education
Committee, 389
Cook, Jonathan M., 101,205
Cook, Joseph A., 255
Cooper, Saladin A. T„ 422
Cooper, Scott S., 187

Cordell, Cari L., 392
Cordon, Krista J., 392
Cornell, Paul J., 67
Cotner, James B„ 256
Councilors 2000-2001 , 68
Counts, Brian W„ 392
Cowherd, Kristy Clinton, 206
Cowherd, Robert M„ 256
Craft, Charles W„ 31
Craig-Nunez, Rebekah, 287
Crider, Stacy L„ 392
Criner, Owen K., 392
Cross, Michael J., 120
CT Scans are Helpful in Acute Abdomen
Cases, 125
Culp, William C„ 232
Czerwinski, Witold P., 422

Daidone, Paul E., 256
Daniel, Andrew D„ 392
Danner, Christopher J„ 135
Dannull, Kimberly A., 392
Darrow, Bruce A., 256
Davenport, David G., 422
Davis Jr„ Richard K., 256
Davis Lee, 280
Davis, Jeremy C„ 392
Davis, Kim;, 247
Davis, Orrin J., 256
Davis, R. Keith, 170
Dawson, Justin D„ 256
Day at the Capitol: Arkansas Physicians
Spend Time Lobbying Local
Legislators, 335
DeGray Lake Resort, 226
Denton, Roy E„ 422
Diacon, William L., 135
Dickins, Robert D., 135
Diemer, Heather Melissa, 305
Dobbs, John C., 255
Dominguez-Ventura, Alberto, 256
Donnell, Hugh, 424
Dorzab, Joe Henry, 319
Downtown Little Rock, 289
Drummond-Webb, Jonathan, 422
Duke, Anton L., 255, 256
Duncan, Lynette, 315
Duwuri, Uma, 422

Eagan Jr„ Vernon L„ 422
Eans, Thomas, 66, 424
Eason, Delilah L„ 256
Eberle, Andrea J., 422
Eckert, Michelle L„ 422

428 • The journal

Volume 97

Eckles, Laura L., 135

Ginger, John D., 255

Leibovich, Marvin 410, 411

Eckles, Michael A., 422

Glendenning, Charles C., 288

Jackson, Phillip C., 320

Lian, Fangru, 354

Edwards, Frank D., 256

Golden, William E„ 170, 349,418

Jaderborg, Jana M„ 320

Lincoln, Lance, 424

Eisele, Martin, 377

Goldsmith, Geoffrey, 164

Jarvis, Robert M„ 354

Linskey, Mark Elwood, 354

Elkins, John S., 255

Graham, Donna M., 320

Jazieh, Abdul Rahman, 132

Logan, Charles W., 205, 255

Elliott, Robert E„ 354

Grainger, Judy, 164

Jetton, Christina A., 135

Long Range Planning Committee, 62,

Endovascular Repair of Abdominal

Granberry, MarkC., 128

Johnson, Anthony D., 424

377

Aortic Aneurysms, 250

Granger, Stephanie L., 422

Johnson, Christopher, 424

Long, Eric D., 354

Enhancing Patient Safety Preoperative

Green, Russell J., 422

Johnson, Dwight, 384

Lu, Ellen, 354

Antibiotic Prophylaxis, 418

Greene, Graham F., 170

Johnson, Jill 1, 128

Lueders, Andrew, 424

Ensminger, Bobby 1, 256

Greenwood, Denise R., 424

Johnson, Melissa, 315

Luzietti, Nicholas R, 354

Erler, Brian S„ 202

Guinnip, Paula M„ 422

Johnson, Sandra M„ 86, 287, 354

Ly, Phuong C„ 31

Evans, David M., 391,422

Gunter, Marc, 422
Gupta, Arun K„ 422

Jones, Edward J., 101, 205
Jones, James, 424

Lyle, Carlene W., 31

Jones, Karla R., 354

Family Ties, 270

Jouett, W. Ray, 45

Ma, Frank, 319

Farooq, Etiya M„ 256

Hadi, Ehsan M„ 320

Junkin, Anthony, 424

Mac Brown, Terry, 256

Faulkner, H. N., 424

Hallmarks of Patient Care: History,

Madera, George J., 354

Feild, Theophilus A., 31

Examination, Suspicion, 124

Magie, Jimmie J., 255

Fenton, Ronnie M., 256

Flames, William M„ 320

Kabani, Noor, 31

Maglothin, Doug, 206

Ferguson, Scott, 62, 66, 239

Handloser, Holly H., 422

Kazzas, Nelly, 24

Mahdavy, Mustafa, 354

Ferrell, Amanda, 422

Hanna, Kamil 1., 135

Keadle, William Ray, 288

Making it Count: Physicians Urged to Take

Fincher, Robert L., 31

Hannon, Martin A., 320

Keller, Pat, 385

Active Role in Political Process, 236

Finck, Christine M., 256

Hardin, Alvin Scott, 151

Kelley, Steven E., 98

Malloy, Mark, 31

Fletcher III, James W., 422

Harms, Sally S., 320

Kellow, Amir L., 354

Maloney, Francis R, 391

Florez, James R, 135

Harrell, Jr, . James, 16

Kelsey, J.F., 288

Managed Cared Rarely Touched This

Floyd, Rebecca R., 101, 205

Harrington, Paul 1, 320

Kendall, Jerry R„ 232

Physician’s Life, 156

Foley, Regina R, 256

Harrison, Lonnie E., 135

Kennedy, Robert B., 31

Managing Diabetes Mellitus, 307

Foley, Sean M., 256

Harton, Scott, 320

Kerr, Robert L„ 101, 206

Mancino, Michael J., 354

Formby, Thomas A., 135

Hashmi, Ali Madeeh, 422

Kilgore, Kenneth M., 101, 206

Martindale, Joseph, 386

Fort, David, 288

Hatfield, David L., 416

Kinchen, Delaney L., 354

Mason, James Z., 101, 206

Foster, Jason, 422

Hathcock, Stephen A., 135

Kinslow, Ivory A., 354

Matthews, Joseph W„ 187

Foundation is a ‘Lifesaver’ to Many

Hawawini, May, 422

Kishan, Channarayapatna, 24

Maxwell, Ralph, 205

Uninsured, 11

Hawk, James M„ 320

Knee-Jerk Docs, 185

May, Brett H., 354

Foxglove Bed and Breakfast, 34

Hayes, Richard L., 391

Knight, Dan, 135

McAndrew, Brian P., 354

France, James FI., 422

Hayes, Sidney, 88

Knowles, Glen C., 101, 206

McEwen, Stanley R., 172

Franks, Amy M., 196

Haynes, W. Ducote, 287

Knox, Michael R., 250

McGee-Reed, Ivy V., 135

Franks, Jason A., 288

Hays, Deborah A., 422

Koehler, Kevin R., 354

McKee, John, 343

Frazier, Elizabeth A., 422

Heard, Jeanne, 255

Koenig, Alberts., 101,206

McMinimy, Donald J„ 67

Friedman, Charles M., 422

Hebbar, Prabhat K„ 320, 422

Kocer, Abdul, 424

McNellis, Emily M., 354

Friedman, Mark, 270

Heif, Muhannad M., 320

Kolb, David C., 135

McNellis, Ryan E„ 354

Frino, John, 288

Heifner, John K., 320

Kremp, Richard E., 354

Meadors, Fred A„ 250

From Bartering to Managed Care:

Hendren, Michael C., 255

Krupala, James Lee, 31

Medical Education Foundation for

Medicine Has Drastically Changed

Hester, Joe D., 287

Kubacak, Brian M„ 255

Arkansas, 377

Over the Past 125 Years, 154

HIV/AIDS in Arkansas, 23, 314

Kula, Zbigtniew, 31

Meeker, Chris A„ 135

Holt, Brent E., 320

Kyser, James, 255

Membership Listing, 207

Hopkins, Robert H„ 307

Merrick, Jason A., 354

Gaddam, Venkatarama R., 343, 422

Hornberger Jr., Evans Z., 319

Mhoon, John M., 135

Galli, William P„ 422

Hou, Di, 424

Laffoon, Gregory, 354

Middleton, Toni L., 355

Gallman, Judith M., 47, 52

House Adopts Action Plan for Future, 45

LaMastus, Ken, 367

Milligan, Lynda B., 101, 205

Galloway, William W., 255

Hui, Anthony, 373

Lamps, Christopher A., 31

Mirza, Mashhud Munir, 355

Garcia, Robert, 288

Hutchison Jr., Ernest Lee, 287

Landrum, Samuel E„ 7, 267

Mitchell, Katherine B„ 355

Gardner, Natalie, 11, 82, 270

Lang, Nicholas R, 205

Mitchell, Michael W„ 192

Garner, William ‘Bill’, 287

Langston, Thomas A., 31

Mockingbird Bay Resort on Lake

Garrett-Shaver, Martha G„ 288

Ibrahim, Hossam, 320

Lawrence, Debra C., 354

Norfork, 426

Garrison, James S., 287

Internet Information is a Double-edged

Lawrence, George S„ 354

Mohrmann, Harry, 132

Gaston, Caleb 0., 288

Sword, 111

Learn from and Respond to the Medical

Montanez, Josue, 125, 319

Gaston, John D., 422

Iron Overload and the Heart, 24

Record, 194

Morgan, Justin E„ 355

Gera, Sunil, 422

Irvin, Jack, 319

Learning from the Experts, 47

Morgan, Martha K., 31

Gershner, Ira, 422

Is That So?, 267

Legislative Advocacy - Everyday, All

Moss, Mark, 355

Gibbons, Glenn G., 288

Is the Big City Life Good for

Day, 301

Mountain Harbor Resort, 257

Gibson, GunnarH., 255, 422
Giles, Wilbur M., 66

Everyone?, 189

Lehmkuhl Rachel J., 354

Munir, Muhammad T„ 355

Number 1 2

June 2001 • 429

Nasal Meningioma: Report of One Case
and Review, 416
Negligence or Not, 19
Nelson, Carl, 170
Nelson, Elizabeth B„ 135
Nelson, Richard, 31
New Alliance President Touts Active
Membership, 57

New Service Allows Physicians to
“Connect” With Their Patients, 403
No Longer a Man’s World: Women
Continue to Move Medicine Forward,
83

Nokes, Steven R., 125,1 35, 245, 346, 41 4
Nolen, John R„ 355
Nominating Committee, 373
Norris, Elvin L„ 101, 206
Nunnally, Robert H., 391

Ochoa Jr., Eduardo R„ 355
Officers 2000-2001,68
Older Female Inpatients in Arkansas, 315
Open versus Thoracoscopic Removal of
Left-Sided Mid-Esophageal
Leiomyoma, 247
Orten, Steven S„ 31
Overacre, Robert L, 31

Padilla, Jose S„ 255
Paperwork will Decrease with New
HIPPA Regulations, 113
Pappas, Lila, 135,355
Pappas, Paul H„ 135, 355
Parcon, Paul J„ 355
Partridge, Paige M„ 355
Paslidis, Nicholas J„ 170
Pate, Kimball B„ 391
Paulson, Kathleen, 391
Paxton, Jason S„ 391
Payne, Elisa M„ 255
Pediatric Injuries Resulting from Use of
All-Terrain Vehicles, 351
Peeples, Chester, 171
Peeples, Jody Warren, 255
Peterson, Hilary A„ 391
Petty, Corwin D., 391
Phillips, Craig H„ 392
Phillips, David, 247
Phooshkooru, Vijay R., 392
Pitas, GrzegorzA., 135
Platt, Lucas O., 135
Pogue, Stacey A„ 392
Politics and Medicine, 232
Pond Mountain Lodge and Resort, 357
Porterfield, James G., 392
Posterior Dislocation of the Shoulder
is Uncommon, Hard to Diagnose, 414
Postoperative Care — Inattentive
Approach, 412
Powell, Brenda, 92

Power, Robert C., 255
Preventing Perinatal HIV: Prenatal HIV
Testing and Strategies to Reduce the
Risk of Maternal-Fetal HIV
Transmission, 27
Prince, Audra M„ 392
Progress on the Long-Range Plan, 333
Prompt-Payment Rule Moves
Forward, 269

Prosser, Robert L„ 101,206
Pulaski County Medical Society, 389
Pulmonary Hypertension in Pregnancy, 98
Pyron, Luke D., 392

Quality Improvement Programs Depend
on Team Work, 164

Rainwater, Melissa C., 392
Ramsay Jr., Rex C., 206
Rangaswami, Narayanswami, 287
Ransom, Clarence E., 391
Razer, Hani A„ 160, 202
Recruiting for Rural Arkansas, 191
Reddy, Pramod P„ 420
Reddy, Vijayabhasker, 32
Redman, Anna, 94
Redman, John F., 420
Reported Cases of Selected Diseases, 282
Revard, Ronald E., 255
Ridgecrest Resort on Bull Shoals Lake, 321
Right Ventricular Infarction, 160
Rimawi, Asem, 343
Robertson, John A., 392
Robinson, Martin J., 392
Rodgers, Charles H„ 135
Rodgers, Jr., Porter, 319
Rodgers, Michelle L„ 392
Rogers, Rachel M., 391
Rollow, III, John A., 424
Ross, R.W., 170
Rothenberger, Andrea, 315
Rowe, Tracy L., 391
Rozas, David R„ 101, 206
Rural Physician Represents New Face
of Medicine, 157
Rusher, A.H, 247

Saccente, Michael, 27
Sanchez, Nena, 418
Schechter, Ron D„ 391
Scheer, Blake G„ 311
Schlesinger, Scott M„ 346
Schoettle, Glenn R, 66
Schumann, Gerald M„ 171
Scott, Jane, 255
Scurlock, William, 391
Serial Troponin I Measurements Detect
Recurrent Myocardial Infarction After
Initial Acute Myocardial Infarction, 202
Shah, Shailesh R., 391

Shock, John R, 170
Short, Walter, 391
Sitz, Karl V„ 311
Sitzes, David A,, 391
Sloan, Fredric J„ 101
Smith, Carl V„ 31

Smith, Christy L, 83,115,123,154,
157,187, 236

Smith, Eugene S„ 98, 128, 160, 196,
280, 343

Smith, Jr., Floyd A., 287
Smith, Lynette, 391
Smith, Melanie, 32
Smith, Steven O., 32
Smith, Todd P„ 391
Snyder, Vic, 135
Sosebee, William S., 32
Sotomayor, Edgar A„ 391
Spradlin, Timothy L., 255
Srinivasan, Pattana, 32
Staley, Kelly, 351
Starnes, Harry D., 255
State Senator Awarded National AMA
Award, 123

Stecker, Rheeta M„ 255
Stewart, R. Todd, 32
Stewart, Tracey D., 245
Stockburger, JohnS., 135
Stolz, Gerald, 51,255, 383
Storeygard, Alan, 135
Stough, Dowling B., 287
Stout, Michael D„ 32
Strode, Steven, 287, 389, 424
Stubblefield, William S., 135
Sturner, William Q„ 255
Submerging Technology: Hyperbaric
Medicine, 7
Sullivan, Sarah L., 391
Suspected Insulin Anaphylaxis and
Literature Review, 311
Swarup, Sachin, 32

Tacoronti, Rudolph V„ 32
Taking the Helm, 51
Talley, David, 202
Tanyard Springs, 393
Tarpley, Jon A., 135
Teeter, Stan, 424
The AMS Health Benefit Plan - A
Eulogy, 81
The Big Easy, 115

The Gospel According to ‘Calvin and
Hobbes', 331

The Langston Collection, 283
The Reality of Mammography Utilization
in the State of Arkansas, 132
The Role of Amiodarone in the

Management of Patients with Cardiac
Arrest, 1 96

The Same Lesson Again and Again, 340
Thomas, Audra R„ 128
Thomas, Joanna, 315

Thomson, Robert C„ 255

Thoracic Aortic Aneurysm Revisited, 343

To Merge or Not to Merge?, 302

Tobacco Cessation, 280

Trauma - What Were the Facts?, 241

Triplett, Sheila B„ 391

Tullis, Joe M„ 255

Turner, Frederick C., 354

Turner, Lori W„ 351

Tutt, Richard D„ 255, 392

Tzuoh Hong, Michael, 320

Use of Diffusion-Weighted Images, 346

Valdes, Raymond P., 392
Van Asche, Christopher, 135
VanScoy, Sara Elsie, 392
VanScoy, William R„ 392
Vasudevan, Kanaka, 338
Vasudevan, P„ 338

Vice President Pushes for Patients’ Bill
of Rights, 82

Wagoner, Charles H„ 32
Waheed, Imran, 392
Walker, Ronald, 414
Wallace, Oliver, 101
Waller, John, 392
Ward, Harry, 101
Ward, Kristin, 164
Ward-Jones, Susan, 84
Waters, James D., 32
Watterson, Krista Sue, 196
Weber, Cynthia W., 57, 135
Weber, James R., 135
Welch, Samuel B., 424
Wells, Britton C., 135
West Nile Fever in the United States, 200
West, Donna, 418
What Have You Done For Yourself
Lately?, 235
White, Bruce A., 255
White, Mark, 416
Whitely, Andre B., 205
Wiggins, L„ 247
Wilkins, Jr„ Walter J„ 101
Williams, Dwight M., 274
Wills, Paul L, 255
Wilson, I. Dodd, 101, 135
Wilson, Morton C., 255
Wish You Had Been There, 9
Worrell, Jr„ Aubrey M„ 136
Wroten, David,, 9, 45, 81 113,188,

235, 269, 301,366, 403

Young, Michael C., 385

Zeno'ZLynfl8Q2 -

430 • The Journal

Volume 97

How do you reach 4, 300
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